Wednesday, April 02, 2008

Educating Rita: How we exclude qualified workers

INTRODUCTION
This blog entry begins by juxtaposing a global blood supply with a global work force for purposes of comparison. It then focuses on my view of how roadblocks keep even the most qualified medical laboratory technologists out of Canada. Perhaps this situation exists in your country too?

Canada actively recruits physicians, nurses, pharmacists and other health professionals. See
Recently, there has been a flurry of news about ISBT128 due to AABB requiring ISBT 128 implementation by May 1, 2008, an event that has been more than 10 years on the planning.

There are many benefits to ISBT128 labels and globalization of the blood supply is one:
  • Blood suppliers routinely sell products in the global market;
  • During disasters, blood products may be shared around the world.
The globalization angle caught my eye because I have long been involved in helping medical laboratory technologists and their equivalents (biomedical scientists, medical laboratory scientists, etc.) find work internationally. North America currently has a shortage of laboratory technologists and other health care workers that is projected to worsen due to an aging work force.

ROADBLOCKS
In Canada we need foreign professionals to alleviate staff shortages, at least temporarily, while we educate and train sufficient numbers of home-grown workers. But under the umbrella of protecting public safety we make it difficult for foreign-trained, well qualified medical laboratory technologists to work in Canada.

1. General Certification
The main made-in-Canada roadblock is lack of subject certification in transfusion science and other disciplines. Canada requires general certification provided by the CSMLS, which ceased offering subject certification (except for cytogenetics and clinical genetics) years ago because of cost.

For an example of a program of study, see MLS courses at the University of Alberta. (MLS also has a pre-professional year - MLS website) Note: In Canada MLS at UA is the only integrated MLS program leading to both CSMLS certification and a BSc degree. It has courses such as research projects and molecular genetics that are not included in other Canadian generalist programs.

Other Canadian programs are 2 or 3 years and lead to certification. Although not required, today many students who enter such programs already have university degrees. A few years ago there was a movement to get the integrated BSc as the entry level qualification to the profession, but it failed due to lack of support from government and employers.

The reason this is noteworthy is that lab technologists from the UK and Down Under, aka biomedical scientists, have qualifications that in many respects are more than what is required in Canada yet face significant roadblocks to being able to work here.

Use it or lose it
The effect of general certification is that experienced technologists who have worked in transfusion medicine labs for years, even if eligible to write CSMLS exams, will find it difficult to write an exam that includes questions involving clinical chemistry, microbiology, hematology, and histotechnology. After 5, 10, or 15 years of working in a transfusion service, no one can recall the nitty gritty of other disciplines. Even if they could, the knowledge turnover would make most of their prior learning obsolete.

 Practical implication: Experienced blood bankers from countries such as England, Scotland, the USA, Australia and NZ must get upgrading in other lab disciplines in order to have a hope of passing the certification exam. Upgrading may involve taking a series of refresher courses (many of which do not include the exam competencies) or an entire training program of 2-3 years

Note: The CSMLS general certification exam is based on a competency profile that focuses on outcomes, not content. The competencies do not mention the traditional laboratory disciplines and are not organized around them. However, the exam questions do require knowledge, skills, and judgement in specific content areas.

2. Educational Diversity
A second roadblock is that education and training of medical laboratory technologists varies greatly around the globe. A few examples:

(i) Despite its emphasis on non-discipline specific competencies, Canadian training currently involves clinical rotations in 5 areas: clinical chemistry, hematology, histotechnology, microbiology, and transfusion science. American generalist education does not include histotechnology.

Practical implication: Americans with generalist certification cannot challenge the Canadian certification exam without taking a course in histotechnology theory and practice.

(ii) While Canadian education and training is generalist, other countries focus on specialization. For example, UK certification has multiple routes but often involves specialization right from the start of clinical training. Graduates with an honours degree in biomedical science from a UK educational institution accredited by the IBMS cover multiple disciplines but then get employed by the NHS as a trainee biomedical scientist for 2 years, during which they are required to complete a portfolio that shows their competencies. This training could be all in a transfusion service.

Similarly, NZ and Australian programs also allow candidates to specialize during their clinical training, usually in 2 disciplines.

 Practical implication: UK, Australian and NZ trained biomedical scientists cannot obtain Canadian certification without obtaining practical experience in labs outside the ones that they chose to specialize in. Clinical laboratories are already struggling to train Canadian students.

(iii) The USA allows subject specialization.

 Practical implication: Experienced blood bankers with ASCP or NCA subject certification cannot work in Canada because of the lack of subject certification in Canada.

CASE STUDY - EDUCATING RITA
This is the case of a real person (Rita) whose name and specific details have been changed.

Rita is a UK-trained biomedical scientist who has worked as a biomedical scientist in a transfusion service in England for ~14 years, the last few as a transfusion safety officer (TSO). She has a BSc honours degree in Physiology and Microbiology and worked at the NHS as a trainee biomedical scientist in hematology and blood bank. She now wants to come to Canada with her family and find work in a Canadian transfusion service.

Rita's experience as a TSO is excellent. She has worked with nurses and physicians in an educative role, developed policies and SOPs, conducted audits of transfusion practice, helped implement Better Blood Transfusion, participated in SHOT, developed e-learning packages, presented reports to hospital administration, liaised with regional colleagues, spoken at conferences, and managed projects such as implementation of blood salvage devices and blood tracing software.

There is no doubt that Rita is well qualified to work in a Canadian transfusion service as a TSO, where she would bring a wealth of experience and a refreshing broader perspective. However, Rita is not eligible to write the Canadian general certification exam. She has no practical internship in histology, clinical chemistry, and clinical microbiology. Even if she had practical experience in all required areas, Rita's education and training occurred more than 10 years ago. Recall is difficult and practices have changed.

Bottom line - Rita could contribute much to a Canadian transfusion service but she may not get the chance. One option, assuming her family could afford and support it, is to go back to school for 2-4 years and take a Canadian med lab tech program. Does this sound likely? Is it reasonable? Is it an efficient use of education resources?

What is the wrong with this picture? Why cannot a country that needs qualified transfusion workers put processes in place that are not one-size-fits-all solutions that exclude many of the most qualified candidates and contribute marginally or not at all to patient safety?

With ISBT 128 we have facilitated a global blood supply. Let's figure out how to get a global work force.

More Information
Comments are most welcome.

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Posted by Blut at 7:14 PM 1 comments

Wednesday, February 27, 2008

Signs you live in the 21st century

As usual, I alone am responsible for the ideas in this blog.

Have you seen these lists about life in the 21st century? They usually begin with jokes such as, "You just tried to enter your password in the microwave. "

This blog is not just about "Automating the transfusion service in the 21st century." It is also about "us and them."

The triggering antecedent for the blog was a television program I watched last year (Canada's Next Great Prime Minister) in which college and university students competed to earn a $50,000 educational scholarship and a 6-mth internship with the contest's sponsor.

One of the questions was, "What do you think will be the overwhelming challenge of the 21st century?" As I recall, the replies included stopping global warming and combating terrorism. But none touched upon what I thought would be one of the most challenging problems that we face.

That problem resurfaced when I read the editorial by Suzanne Butch in the March 2008 issue of Transfusion:
  • Butch S. Automating the transfusion service in the 21st century. Transfusion 2008; 48 (3):406-7.
The editorial supplemented a paper describing work in the UK to develop and test a system for total electronic control of the blood transfusion process:
 The UK study evaluated remote blood issue combined with an electronically controlled transfusion process and found that it reduced the time to make blood available for surgical patients and improved transfusion efficiency.

Briefly, the electronic process is as follows:
1. Before transfusing blood, staff use a hand-held computer to make multiple scans prompted by the device:
  • Staff's user identification bar code
  • Identification bar code on patient's wristband
  • Blood unit compatibility label, unit number, and product code
2. The hand-held computer
  • Confirms if the bag is correct for the patient; if not, indicates "Do Not Transfuse" and sounds an alert
  • Prompts users to
  • -->Orally clarify patient's identification (first name, surname, and date of birth) and to check all details displayed on the computer screen
  • -->Perform other essential pretransfusion checks, including unit expiry date
  • -->Enter pretransfusion patient observations into computer
  • Once these checks are completed, prompts users that it is safe to begin the transfusion.
3. A final transfusion report, including observations done during and after transfusion, is printed and kept in the patient's medical records.

4. Information from the hand-held computer is downloaded to a blood bank computer by docking into a computer or by a wireless connection to the hospital network.

[For more on bar codes and RFID, see TraQ's Technology clearinghouse.]

In her editorial Butch notes that technology to improve transfusion safety and documentation has been available since the 1990s but few facilities have implemented total electronic patient identification from specimen collection to testing and transfusion.

She says that now is the time to ask software vendors and instrument manufacturers to develop such systems, whether using bar codes, RFID, or other technologies, in order to provide safer and more efficient use of blood components and human resources. She notes that, although it will be costly, in the USA forces such as the Joint Commission and CAP now advocate better patient identification systems.

Which brings me to the underlying theme of this blog: us and them

We in the West are spending or are preparing to spend a large amount of money to approach total positive identification and reduce transfusion errors caused by misidentification to zero or near zero. Although such errors are rare, we naturally strive to make them even rarer. And we already spend vast sums to prevent transfusion transmitted diseases, some of which are themselves very rare in our societies.

All of which is wonderful - wonderful for us.

But what about blood transfusion in developing countries? A few newspaper items are instructive:

Vietnam: Many in poverty earn a living selling their blood (Feb. 2008)

China: Deadly blood trade (Nov. 2007)

India: Professional blood donors may soon be jailed (Nov. 2007)

India: Most blood banks are not equipped to carry out even mandatory tests for diseases like AIDS, hepatitis B and C (May 2007)

Peru:Families of children infected with HIV via transfusion demand compensation (Sept. 2007)

Trinidad & Tobago: Desperate patients are charged 100s of dollars for a pint of blood (Dec. 2007)

US AND THEM
The contrast is clear. We operate Mercedes Benz blood transfusion systems whereas they run horse and buggy operations, if that. We use expensive technology to make transfusion not only safer but more efficient. We have the luxury of striving to be more efficient in a world where transfusion, indeed life, is unsafe for so many.

So what, you say? That's just the way it is in the world and it's not specific to transfusion. In everything, we are haves and they are have-nots. All correct.

Just think that every year there are 500 million - 1/2 billion - new cases of malaria in the world and that every 30 seconds a child dies of malaria (see WHO - Malaria). The numbers for those dying of diarrhea and other preventable conditions are equally staggering. These overpowering problems leave transfusion medicine barely on the health care map in developing countries.

In contrast, we in the West spend millions on food and medical care for our pets, eat ourselves into obesity, complain that we can never remember our passwords because we have too many, and diligently strive to make blood transfusion zero-risk.

And that's a problem - a BIG problem, if not THE problem of the 21st century. With modern communication systems reaching every part of the globe, how long can such inequities continue? How long before the have-nots do something about it? And how can we in good conscience just stand idly by and continue to accept our good fate?

Perhaps the Transfusion papers made me think about global disparities because I have friends working in blood transfusion in Vietnam and Cambodia. They work for a pittance - it is more like volunteering. Their informal reports on the reality is more than you could imagine. Think the worst, then multiply it a 1000 fold.

What can and should be done about these disparities? What can we do as individuals? Some possibilities:
 Just some food for thought as we go back to fretting about all the things we fret about in our daily professional lives....

Signs you live in the 21st century really depend on where you were born and live.

If you know of more organizations where individuals can help or would like to give feedback, please click on the comments link below. There are already 2 thoughtful commentaries - many thanks to the contributors.

NOTE:
For those of you who read the blog below (To consolidate or not to consolidate? Who shall inherit the wind?), there have been several comments added.

New on TraQ
Posted by Blut at 6:35 PM 3 comments

Saturday, January 19, 2008

To consolidate or not to consolidate? Who shall inherit the wind?

This blog entry's title is a take-off on He that troubles his own house shall inherit the wind...(Proverbs 11:29), i.e., if you create problems for your own community, even if inadvertently, it will come back to you in some way. The play Inherit the Wind, whose title comes from the biblical proverb, is about limiting an individual’s freedom to think. These themes run throughout this blog.

By serendipity I came across the blog, Save our Blood Service, subtitled "Don't mess with the NBS". The blog's purpose appears to be to try to prevent centralization of the UK National Blood Service and to inform workers about related events.

 NOTE: The discussion that follows represents my personal views alone.

The UK plan to go from 14 centers to only 3 centres is currently being reviewed (possibly due to widespread opposition by staff?) with a decision expected shortly. From what I can tell, the planned reorganization has been in the works since at least the Fall of 2006. There are no doubt multiple rationales for the plan, but a major one must be saving money. And since staff accounts for a major percentage of costs, presumably staff layoffs will occur. Accordingly, there have been protests over blood centre cuts.
Canada experienced a similar process in which CBS consolidated to 3 testing centres for the entire country (except for Quebec, where Héma-Québec is the blood supplier), as well as other reorganizations such as using one consolidated call centre.

From my perspective, despite efforts by CBS, the Canadian initiative was preceded by years of uncertainty in which staff first wondered if their centre would be one of the lucky ones to remain as a test site, followed by more anxiety about what would happen to them once they knew for certain that their centre was toast, test-wise. Telling staff that they were being kept apprised of decisions, providing communication mechanisms to alleviate concerns, and promises of support to help staff obtain new employment did not appear to lessen the angst significantly.

Over the years, it has seemed to me that when restructuring occurs that threatens significant layoffs - such as the massive changes that happened in Alberta in the early to mid-1990s - some management decisions have been temporarily held back from front line staff ostensibly to facilitate their ability to focus more positively on the work at hand. Of course, it is a policy never admitted to publicly.

The powers-that-be may act paternalistically and appear to believe that staff cannot handle bad news that threatens their livelihood. Moreover, a relatively common scenario, particularly for letting middle management and more senior staff go (valued, long-term employees), involves telling them at the very end of a business day that their services are no longer needed, simultaneously removing their computer access, and escorting them to the door. These practices do not engender loyalty in staff who remain.

As to CBS restructuring and what it accomplished, in March 2002 CBS had 4756 staff employed mainly in 14 regional centres. In 2001/02, blood operations expenditures were $351 million, a 14.7% increase over the previous year.Combined administration/overhead for the national level and regional centres was $85.4 million, representing 24% of blood operations expenditures.
  • Source: Performance Review of Canadian Blood Services. Final Report (Oct. 15, 2002)
I do not know how many staff are now in blood operations and realize that new initiatives may have increased staffing in some areas. But presumably there are valid comparisons that can be linked to consolidated testing and restructuring.

So.....DID CBS RESTRUCTURING SAVE MONEY - HOW MUCH?

One of the goals of creating CBS in 1998 after the so-called tainted blood tragedy documented by the Krever Report was to achieve transparency. To my knowledge, although CBS annual reports have outlined in general terms some of the efficiencies and benefits resulting from restructuring and consolidated testing, CBS has never published a comprehensive report documenting what was achieved financially as savings to tax payers who fund the service, and documenting benefits to hospital clients (transfusion services) and improved patient safety. If such a report exists, I'm sure my esteemed colleagues and friends in CBS will show me the light. (big grin)

If the UK NBS plan goes ahead, staff would find it useful to know ahead of time what the proposed advantages are, not just in terms of motherhood claims (it will save money; it will result in improved services to hospitals, etc.) but in terms of financial savings and other hard criteria against which success can eventually be measured. My experience has been that staff appreciate being told the straight goods. As well, should layoffs result, treating staff respectfully as valued employees, and as adults who deserve to know the reality in order to plan their futures, should be a given, indeed, a priority.

Personally, I will find it fascinating to see if the UK plan goes ahead and, if yes, in what form. If a country the size of Canada, the 2nd largest in the world, can have but 3 test centres for English Canada, it would seem that the UK can. Some of the key questions are
  • What are the savings and how will they be realized? (staff, equipment, overhead, etc.)
  • How many staff will be laid off or otherwise dealt with?
  • Are there significant benefits besides saving money?
Equally fascinating will be examining why the plan did not go ahead, if it does not. Protests did not stop the massive restructuring and downsizing that happened in Alberta in the '90s. But it's reassuring to see people try to influence the decision makers and inform colleagues, such as whoever created Save our Blood Service has done.

The blog's title is somewhat ironic because people who argue for restructuring typically cite change as being necessary for survival and see change as the way to save the system. The question is, what kind of change and does it really achieve its stated goals. If you do not get it right, you generate continuous cycles of centralization and decentralization that are satirized in A surrealistic mega-analysis of redisorganization theories.

Regardless, blogs have a bottom-up approach, a form of people power that I admit to liking. Kudos to the person behind Save our Blood Service!

Feedback is welcome - please just click on Comments below.

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NOTE:The following feedback was provided by Ian Mumford, Chief Operating Officer, Canadian Blood Services, who gave permission to post it.

Pat-- Your blog was recently brought to my attention. Although you offer opinions on a wide range of issues I want to specifically respond to your January 19, 2008 comments regarding the consolidation of donor testing within Canadian Blood Services.

It appears you are uncertain as to the reasons for the consolidation. The objectives were very clear, right from the beginning. The primary objective was to increase the safety of the blood supply. This objective was the overriding factor for all decisions.
Improving safety was done by:
  • Introducing new technology with improved sensitivity, specificity and reproducibility
  • Creating an environment that expedites the assessment of new tests, methodologies and instruments
  • Decreasing the amount of time required to implement new tests that address emerging threats
  • Standardizing processes across CBS
  • Enhancing process control through automation
  • Moving to an integrated, fully GMP compliant, quality-driven system
The secondary objective was to increase the cost effectiveness of testing.
Improving cost effectiveness was done by:
  • Streamlining and improving the processes in place
  • Maximizing the testing throughput for expensive, highly automated testing equipment
  • Increasing cost management by standardizing consumables and supplies and leveraging a national procurement process
As you note a number of staff were impacted. A comprehensive Career Bridging program was developed for those staff. The program included educational and relocation allowances in addition to severance packages (as provided for in collective agreements). Staff members impacted by the consolidation of testing were given priority for available positions if they wished to relocate to a future consolidated testing site. A number of staff took this opportunity and many have had careers with progressive responsibility as a result. In addition, some staff members at a future consolidated testing site who were impacted by the MAK Progesa implementation were able to be reassigned to testing and other staff members found other job opportunities within CBS.

So what has happened?

The primary objective for increased safety of the blood supply has been met. The three Donor Testing laboratories are now highly automated with testing platforms that are the state-of the art for donor screening, e.g. the Abbott PRISM for serological transmissible disease testing and the Roche s201 system for West Nile Virus testing and Galileo for antibody screening. Most processes have been standardized with clear points of process control, many of which are automated. Standardization of processes has permitted staff transfer to an alternate site for short periods to manage implementation of major projects. A laboratory information system (LIS) has been implemented to increase process control for the automated transfer of test results from test equipment to LIS and after appropriate review, the upload of these results to MAK Progesa for the appropriate management of donors and blood components. There has been a decrease in testing critical non-conformances. We have had increased agility to introduce new tests such as West Nile Virus in response to an emerging threat. WNV was implemented in less than six months, an achievement that could not have been contemplated before consolidation. We now have the ability to manage single unit WNV testing during the infectious season on a real time basis.

The secondary objective for increased cost effectiveness in donor testing has also been met. The project expected to decrease the cost of baseline testing by 6% in the first year. This objective was exceeded by 100%, the first year on going costs were reduced by 12%. There has been continuous improvement in cost management year over year through efficiencies in utilization of assay kits and reagents and standardization of consumables and supplies.

Over the last decade, donor testing has continually increased in complexity and the level of technology available. These changes, which have improved the safety of donor testing, have made the concept of multiple, small laboratories unsustainable practically and economically.

Change is always challenging, especially for those directly involved and I can appreciate that all of the communications and support we provide may not lessen the angst. It's interesting that although some staff want to know about even the possibility of change months and months in advance, others tell me they only want to be informed when final decisions are made and a way forward is set.

Overall the consolidation of donor testing was successful and impacted staff were treated with the upmost of respect.

Ian Mumford
Chief Operating Officer
Canadian Blood Services


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Posted by Blut at 6:27 PM 3 comments

Saturday, December 15, 2007

Hell, no, I won't go? (musings on pandemic flu)

In the 1960s, a famous antiwar mantra about Vietnam was, "Hell, no, I won't go!" This blog's title is a take-off on that phrase as related to who of us will show up for work during a flu pandemic.

Having just participated in a provincial project to develop a contingency plan for blood shortages due to pandemics and other disasters, I got to wondering how many hospital transfusion services (TS) have developed such plans and particularly about contingencies for staff shortages.

For example, what would happen in your TS during a a flu pandemic, if a significant percentage of staff (30-40% or more) were too sick to work, some stayed home to take care of children or other family members who were ill or because schools had closed, and others stayed home out of fear of becoming infected in the hospital?

For interest, in Canada during the SARS crisis of 2003, health care workers (HCW) were at great risk. One small study showed that among 43 nurses who worked in two Toronto critical care units with SARS patients, 8 of 32 nurses who entered a SARS patient's room were infected.
A larger study showed that of 74 SARS cases reported during April 15 -June 9 to Toronto Public Health, 39% occurred among health care workers, 38% occurred as a result of exposure during hospitalization, and 23% occurred among hospital visitors.
Given that much has been learned from the SARS crisis, today, would you put the duty to care for pandemic flu and other patients above potential health risks to yourself and family and above your responsibility to care for your family?

 For overviews of these issues, see:

1. Hospital pandemic preparedness: health care workers’ opinions on working during a pandemic. Med J of Australia 2007; 187 (11/12): 676.
  • Key findings:
  • 67% would work during a pandemic;
  • 26% would stay home to care for dependents;
  • 10% admitted they would stay away because of fear of catching influenza.
2. Will first-responders show up for work during a pandemic? Lessons from a smallpox vaccination survey of paramedics. Disaster Manag Response 2007 Apr-Jun;5(2):45-8.
  • Key findings:
  • More than 80% of respondents would not remain on duty if there were no vaccine and protective gear;
  • Even if protective gear was available but the vaccine was unavailable, only 39% of respondents would remain on duty.
3. Influenza pandemic and professional duty: family or patients first? A survey of hospital employees. BMC Public Health. 2006; 6: 311.
  • Key findings:
  • 28% agreed that it would be professionally acceptable for HCW to abandon their workplace during a pandemic in order to protect themselves and their families;
  • 77% disagreed with the statement that HCW should be permanently dismissed for not reporting to work during a pandemic;
  • 21% of respondents agreed that HCW without children should primarily care for the influenza patients.
BLOOD CONTINGENCY PLANS
Most of the publicly available plans are designed to offer guidance at a national level, and, as would be expected, tend to focus mostly on the blood suppliers. See Further Reading below.

Blood shortage preparedness for hospitals is built around the twin pillars of
(i) Practicing sound blood management at all times;
(ii) Inventory levels triggering the contingency plan, at which point hospitals are expected to cut back on inventory and begin to triage which patients will be transfused and which will not.

In Canada several provinces are developing blood contingency plans targetted to hospitals. These plans are based in part on the UK integrated blood shortage plan (see Further Reading below) and provide guidelines for TS to use in developing their own plans. Only a few forward-looking hospital regions have begun planning for severe blood shortages that would occur during pandemics. Almost all have plans for short term shortages caused by mass casualties and similar events.

Existing blood contingency plans are mostly designed to cover blood shortages regardless of cause, e.g., pandemic, terrorist attack, natural disaster, mass casualty accident.

Hospital-focused plans tend to assume that associated problems such as power outages, transportation disruption, communication failures, and staff shortages with be covered by hospital emergency preparedness plans and regional emergency planners.

Emergency preparedness planners mainly use the Incident Command System (ICS) model to develop to their plans. Most people in the transfusion medicine community have never heard of ICS. (Also see information on disaster response systems in Canada)

STAFF SHORTAGES
Transfusion services must be prepared for severe staff shortages. In pandemics, the effects of a staff shortage may be lessened because fewer transfusions will occur due to a shortage of blood donors. Laboratories that use manual test methods and procedures that are more labour intensive will be hit hardest.

There are many strategies that TS labs can use to develop contingencies for staff shortages. Most revolve around identifying core services that must be maintained and ensuring an adequate supply of trained staff to perform them.

Bottom line: The results of research into the attitudes of HCW to caring for families and protecting their own health during pandemics suggest that preparedness strategies need to extend beyond the logistics of ensuring adequate staff. Equally important will be
  • Staff education about pandemics and how the disease is spread, combined with
  • Equipment and other strategies designed to protect HCW from infection.
QUESTIONS (food for thought)
  1. Does your hospital have a blood shortage contingency plan?
  2. If yes, does it include contingencies for staff shortages?
  3. Have you received education about pandemic flu?
  4. How do you think you will be protected when you come to work during a flu pandemic?
  5. Do you know who will be given priority for available vaccine during a flu pandemic?
  6. Other than being ill, under which circumstances would you not show up for work during a flu pandemic?
  7. As a health professional, would you risk your life for others or is it Hell, no, I won't go?
If you care to contribute ideas or feedback, please comment below, anonymously or attributed.

New on TraQ

Further Reading (all PDF)

WHO. Maintaining a safe and adequate blood supply in the event of pandemic influenza. Guidelines for national blood transfusion services (19 May, 2006).

CANADA
UK
USA
Posted by Blut at 5:49 PM 0 comments

Sunday, November 04, 2007

Musings on the blood business

Several recent papers got me to focus once again on transfusion medicine as a business instead of as a branch of medicine. Some musings:

1. The first paper is an editorial in the 25 Sept. issue of the Canadian Medical Association Journal featuring a systematic review in the same issue on the use of erythropoietin in critically ill patients.
 One finding of the review was that when the treatment (costing ~$400/dose) is used off-label for critically ill patients, it typically saves less than one unit of blood, does not improve clinical outcomes, and potentially results in more thrombotic complications.

The editorial authors note that, in the USA, erythropoietin manufacturers have aggressively promoted the drug via direct-to-consumer advertising and incentive payments to physicians. The editorial mentions that, while off-label use may lead to treatment innovations, they also create a loophole for drug manufacturers to bypass regulatory oversight designed to protect patients.

2. The second paper is in the November issue of Transfusion:
The authors present as background these facts:
  • Since its introduction in the 1980s IVIG use has steadily increased (since 1990 at an average annual rate of 12.5 %).
  • Off-label uses have grown significantly.
  • In Canada there is no direct charge for individual patients or hospitals for IVIG: provincial governments are billed annually by Canada's two blood suppliers (CBS and H-Q) for blood products used the previous year.
  • CBS convened a national conference in 2000 on IVIG utilization: a key recommendations was for provinces to develop utilization boards.
  • BC was the first to develop a utilization board and their report on IVIG utilization suggested that approximately 50 percent of IVIG use was for off-label indications. Also see
3. The last of the recent articles is from the 25 Sept. issue of CMAJ. The title says it all, but the humorous piece is about an attempt to develop and market a drug for premature ejaculation; the sub-theme is disease mongering:
All of which harkens back to two other humourous yet serious articles featured earlier on TraQ (both are full free text):
Hope you enjoy the articles and their underlying messages to us as health providers.

Cheers, Pat
Posted by Blut at 6:00 PM 1 comments
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Sunday, September 02, 2007

What's up doc? Welcome to docovigilance

This blog results from my take on two articles on vigilance schemes to promote transfusion and transplant safety:

1. AABB News article: Hemovigilance to biovigilance. An evolution of transfusion safety

Hemovigilance can be defined as
  • A set of surveillance procedures, from the collection of blood and its components, to the follow up of recipients to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products, and to prevent their occurrence or recurrence.
Source: IBTS website

The article in AABB News points out that biovigilance goes beyond blood to incorporate tissue, organ and cellular products. For many years the AABB has been working to expand beyond blood transfusion to include standards for cells, tissues, and organs.

Biovigilance -- nice name! Biovigilance can be defined as

The detection, gathering and analysis of information regarding the untoward and unexpected events of blood transfusion and transplantation of cells, tissues and organs, with the objectives of:
  • early warning of safety issues
  • exchange of valid information
  • application of evidence for practice improvement
  • promotion of educational activities
Source: A National Biovigilance Network

2. The second article was part of Improving blood utilization - Session 3 in the conference proceedings published as a supplement to the August issue of Transfusion:

The Role of Blood Centers in Transfusion Recipient Care. Second Joint Conference of America's Blood Centers and the European Blood Alliance

All of the blood utilization presentations are worth reading but this one caught my eye:

Dzik S. Use of a computer-assisted system for blood utilization review. Transfusion 2007;47(s2): 142S

The author's hospital uses multiple blood utilization strategies, including a hospital transfusion committee, educational conferences for clinicians, wallet cards with reminders of transfusion guidelines, and more. But the presentation focuses on
  • Computerized physician order entry (POE)
  • Computer-assisted blood utilization review and feedback
In brief, the computer-assisted system functions as follows:

1. All routine blood requests occur via POE software. Criteria for blood usage review are displayed on the computer screen at the time of the request. An unusual request triggers a pop-up window that alerts the physician to a possible error in the order. For blood components, a reason for transfusion must be selected before the software will process the order.

2. Once daily, a program automatically generates a report that identifies all patients transfused in the past 24 hrs, along with demographics such as age and sex, as well as pretransfusion lab results.

3. Patient reports are compared with criteria for RBC and FFP transfusion and those not meeting the algorithms are flagged for daily reports that include pretransfusion and post-transfusion lab results.

4. A TM physician reviews the daily reports and physicians who made questionable decisions to transfuse are targeted for education.

A non-judgmental e-mail is sent to the clinician within 24 hours of the decision to transfuse.The e-mail displays the pre- and post-transfusion lab data; provides the criteria for the review process; and links to an in-house educational site.

On the website, for each blood component the physiology of blood use is summarized and articles on the clinical use of blood are listed. Each article is linked to a summary of the paper's findings and to the published paper.

The e-mail invites the physician to reply if there are questions or concerns.

The author acknowledges that the program is rudimentary and that much could be done to improve its capabilities and expand future uses.

DOCOVIGILANCE
It struck me that what Dzik's computer program does is docovigilance, which can be defined as:

A set of surveillance procedures, from the ordering of blood and its components, to the follow up of recipients, to collect information on a physician's (doc's) decision to transfuse and to
  • assess prospectively whether or not transfusion is warranted and, if not, to prevent its occurrence by alerting physicians to possible order errors
  • assess retrospectively whether or not the transfusion met established criteria and, if not, to prevent its likelihood of recurrence by physician education
There's considerable potential for docovigilance. Dzik mentions several future uses, including
  • Monitoring the decision not to transfuse
  • Providing summary statistics on how each clinician's performance compares with that of peers (benchmarking)
  • Generating data on transfusion decisions across many patients and linking data to patient outcomes with a view to assessing transfusion guidelines
Seems that docovigilance has growth potential. To an innovative computer company, it could be an opportunity for growing the business.

Hemovigilance to biovigilance to docovigilance. Thar may be gold in them thar hills! Of course, creating a viable product from a good idea is fraught with difficulties. Just think of artificial blood substitutes like hemoglobin-based oxygen carriers....

One last musing.... Despite receiving extensive education in transfusion science while an under-graduate, if a medical laboratory technologist who had worked in chemistry or another area of the clinical laboratory for many years was hired to work in a transfusion service, the technologist would receive comprehensive re-training and competency assessment before being allowed to perform pretransfusion testing.

Yet physicians are permitted to prescribe transfusions with only a few hours, if that, of transfusion medicine education. What is wrong with this picture?

New on TraQ
Posted by Blut at 4:24 PM 1 comments

Monday, August 06, 2007

Hawthorne effect in transfusion research - a thorny issue?

I first came across the Hawthorne effect (HE) when taking a Masters of Education after teaching for 10 years. Teaching and then getting formal qualifications may seem bass-ackwards but that's how many health professionals do it. You get into teaching because you like it, then take another degree once you decide to make it a career.

Recently, I was surprised to see reference to the HE appear in a recent paper in the Supplement to the August 2007 issue of Transfusion. The Transfusion supplement reports the proceedings of this conference:
  • The Role of Blood Centers in Transfusion Recipient Care. Second Joint Conference of America's Blood Centers and the European Blood Alliance
The HE is usually defined as the tendency of research subjects to act atypically as a result of their awareness of being studied, as opposed to any actual treatment that has occurred, and has come to be one of the confounding variables that applies to behavioral research.

The HE got its name from a project (1924 - 1932) by researchers from Harvard Business School on the impact of improved working conditions on productivity done in the Hawthorne Plant of the Western Electric Company (now Lucent) near Chicago.

A major finding - the one that became known as the HE - was that, regardless of the experimental manipulation, worker production seemed to improve. Researchers concluded that the workers were pleased to receive attention from the researchers, who expressed an interest in them, and therefore worked harder.

Since then the HE (which I have come to call the on stage effect) has been broadened to relate to almost every kind of human behavioral research, including educational, clinical, and transfusion medicine research.

Note that the original Hawthorne research was flawed and its findings suspect. For example, the most famous and longest study (1927 - 32), and the one giving rise to the HE, involved only five women, two of whom were replaced mid-study for insubordination and slow work with faster, more compliant workers. See:

Regardless of the validity of the original research, the principle of the HE, that observation may have a significant influence on a study's outcome, seems to have life as a possible confounder in studies involving human behavior.

The HE is mentioned in this paper of the Transfusion supplement:

Tinmouth A. Reducing the amount of blood transfused by changing clinicians' transfusion practices. Transfusion 2007 Aug;47 (s2):132S-136S.

The research involved a systematic review to evaluate published literature to determine the relative effectiveness of interventions to improve transfusion practice. Researchers identified 25 studies from 1983 to 2005 that examined intervention effectiveness and provided data both before and after the introduction of the intervention. The most commonly used interventions were guidelines, education, and audit with feedback. Tinmouth concluded that


  • Published literature suggests that even simple interventions may be effective
  • Data are very limited because of the poor quality of the studies
  • Confounders include lack of controls, publication bias, and the HE

Tinmouth recommends that more randomized controlled studies be done to properly evaluate strategies to improve physician practice.

The conference proceedings includes many papers that will interest laboratory, nursing, and medical transfusion specialists and is highly recommended. Sample breakout sessions include:

  • Right patient, right blood
  • Improving blood utilization
  • Optimizing blood center-hospital relationships
  • Better blood recipient, inventory & supply chain management
As to the HE, I suspect that it illustrates something that I have always believed and regularly practice:

  • Never let the truth get in the way of a good story
Cheers, Pat





Posted by Blut at 4:52 PM 0 comments

Tuesday, July 03, 2007

Sharing the heavy lifting at conferences

This month's blog is meant to stimulate discussion.

Today transfusion medicine (TM) associations are largely composed of medical laboratory technologists*, nurses, and physicians and not in equal numbers. In many TM associations, from most to least, it's often technologists -->physicians-->nurses, although the number of nurse members is growing. Other groups also belong to TM associations, e.g., scientists, recruiters, administrators, industry representatives, etc. But for purposes of this blog, I'll stick to the doc-tech-nurse troika, where a "doc" could be an MD or PhD level scientist or MD-PhD.

So why is it that at many conferences the speaker list is mostly docs with technologists and nurses a definite minority on the programs? Today more non-doc health professionals are speaking at conferences than in the past, but there is still a way to go.

And there may be a difference between countries as well. A quick glance at the AABB program shows something for all, as shown by Saturday's program for 2007

Similarly the May CSTM conference program had a selection of topics targetted at techs and nurses, with speakers from each group.

It may be my imagination but are there fewer non-docs in this Down Under program?

Possible rationales for the preponderance of doc speakers at TM conferences:

1: Annual meetings are scientific conferences and docs do the bulk of research. True, but should not conferences represent the interests of all an association's members? And there are many topics that involve research and best practices that could be presented by non-docs.

2. Only docs can afford to go to conferences these days, or possibly are better funded by their employers. And docs tend to listen only to other docs. Okay, this one's slightly tongue-in -cheek...

3. It's a hangover from the old days when the physician was the paternalistic "captain of the health care ship", in which "father knows best". See

As someone who has spoken at many conferences over the years, I know that presenting is heavy lifting. It's more onerous if you need to create a brand new talk, as opposed to updating the same talk given many times before.

But there are many types of heavy lifting. For example, if you examine TM conference organizing committees, in Canada it's typically a physician who is the conference chair, co-chair, or scientific chair and he or she works long hours as a dedicated volunteer. However, it's often technologists who do most of the heavy lifting required to put on a successful conference. And usually their trench work happens after hours, eating into family, relaxation, and recreational time. The case can be made that it's a matter of technologists being more numerous than docs, but I suspect that it's more than that.

Volunteering is wonderful but it's only just that the load be shared equitably. I'm unaware of the situation in other countries that rely heavily on volunteers to organize conferences.

As an aside, I use the term volunteer loosely as sometimes staff are told they are volunteering.

In summary, many presentations by docs are relevant and of interest to non-docs. But it benefits everyone when all professionals in the TM community are active participants in the presentations at conferences, not relegated mainly to trench duties, and when every team member's expertise is validated by the honour of being an invited speaker.

I think it's a sign of a discipline's maturity and strength when there are lots of non-docs on the conference program. It would be nice to see more docs on organizing committees too.

Just some food for thought....

------------------------------------------------
* also known as clinical laboratory scientists, medical laboratory scientists, and biomedical scientists
Posted by Blut at 7:24 PM 1 comments

Tuesday, June 05, 2007

Informed consent for transfusions - take this job and shove it?

If you know someone who has had a transfusion recently, ask them if a physician or nurse explained the risks and benefits and, if during or after their hospital stay, they were notified in writing that they were transfused. Chances are, maybe not, even though both policies have been promoted as best practice for years now.

In Canada more than a decade ago Justice Krever (Commission of Inquiry on the Blood System in Canada), made recommendations on informed consent and documentation:

To quote Capen:

  • In March 1995 the Krever inquiry released an interim report, which contained a strong warning that the informed-consent requirement applies specifically to the administration of blood or blood products, and the routine consent form signed upon admission to hospital does not fulfil this requirement.
  • It also said physicians should prepare patients well in advance of scheduled surgery to give them adequate time to consider reasonable alternatives.
  • As well, doctors should provide information on these alternatives.
  • The interim report said doctors must ensure that documentation occurs every time consent is provided, and that all treatments or procedures are recorded in the chart.
Despite inclusion in blood safety standards, many transfusion services in Canada and around the globe are still developing processes for informed consent and documented notification of transfusion. A paper by Canadian authors and editorial in the April issue of Transfusion deal with these related issues:

  • Killion DF, Schiff PD, Shoos Lipton K. Informed consent: working toward a meaningful dialogue (editorial) Transfusion 2007 Apr;47 (4), 557-8.
  • Rock G, Berger R, Filion D, Touche D, Neurath D, Wells G, Elsaadany S, Afzal M. Documenting a transfusion: how well is it done? Transfusion 2007 Apr;47(4):568-72.
In brief, Rock and coworkers did a retrospective review of 1005 patient charts with these results for documentation of informed consent and transfusion:

  • In 75% of cases the physician had not documented that any discussion had occurred regarding the risks and/or benefits or alternatives.
  • Only 12% of charts included information that patients were subsequently told what blood components were transfused.
  • The discharge summary recorded transfusion information in 32.1% of cases whereas the consult note had this information in 26.3%.
If informed consent is still not a reality, why not? The editorial authors propose as possible mitigating factors (1) distressed patients in pain and (2) health professionals who are rushed. They offer the following suggestions as a follow-up to the Rock study:

  1. Perform more studies to determine how widespread informed consent is
  2. Change the current model of informed consent so that, instead of relying heavily on physicians, who bear ultimate legal responsibility for transfusion, trained transfusion staff be used to obtain informed consent.
The advantages are that transfusion staff understand the risks and benefits of transfusion, as well as patient needs, and are better equipped to follow through with documentation.

To meet best practice standards most transfusion services in Canada are actively promoting informed consent and documentation:

CHANGE THE MODEL?
Informed consent for transfusions - whose job is it, anyway? Is the answer to change the model and shift obtaining informed consent to trained transfusion staff? And who would these staff be? Nurse transfusion specialists? Transfusion safety officers, whether medical laboratory technologists or nurses? In some Canadian hospitals nurses already handle informed consent. What problems may this shift to transfusion staff potentially create for physician responsibility for transfusion when the inevitable mistakes are made?

In pondering the issue of shifting responsibility for informed consent, I could not help but think of a shift in responsibility that happens in some rural hospitals. In towns where the laboratory is not staffed after hours by technologists, nurses are asked to issue blood from the transfusion service. Presumably they are trained in issuing procedures, but how well is open to debate. And in some locales nurses have refused to issue blood, claiming it is an effort to shift work from the laboratory to the nursing staff, in effect making nurses subsidize the lab service, which saves money by not running the lab after hours.

Is the suggestion of a new model as proposed by the Transfusion editorial another example of offloading responsibilty to others, others who are supposedly less busy than physicians? Or is this view too cynical? With patient safety coming first (not politics), is the proposed model simply a pragmatic view - do what works best for the patient. Regardless, any new model must proactively deal with potential problems caused by a shift in responsibilty for informed consent to transfusion staff.

Lastly, how representative is the Rock study of Canadian hospital performance in obtaining informed consent from patients and providing written documentation of transfusion? We can only speculate. If you are not Canadian and think your hospitals perform better, my quess is, think again. The problem is likely widespread in the USA, the UK, and elsewhere. You will not know without extensive audits.

Clearly, much work remains to be done in fulfilling some of Justice Krever's most basic recommendations. In the meantime, informed consent seems to a case of take this job and shove it!

**Be sure to check out the "comments" section below.**

Posted by Blut at 10:48 PM 2 comments
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Monday, May 07, 2007

"STOP! Check the patient's wristband."

There is an excellent paper involving six countries by the BEST Collaborative in the May 2007 issue of Transfusion:
The paper has much to recommend it:

1. The research concerns transfusion to the wrong patient, which is the most important serious avoidable hazard of transfusion. It's always nice to read research that tackles transfusion issues that are both serious and common, i.e., ones that are clearly and directly significant to transfusion practice and patient safety. And after complaining about the content of Transfusion and its relevance to practice for technologists and nurses in an earlier blog (Whither immunohematology in AABB's Transfusion? ), the May issue is loaded:

2. The paper reports on a simple low technology intervention for reducing patient identification errors, namely a sticker tag that visually reminds transfusionists to stop and check the patient's wristband and requires removal to spike the unit.

  • The sticker reads, "STOP: Check the patient's wristband."

Low tech processes that work are bound to have wider applicability in smaller rural transfusion services and in the developing world.

3. An accompanying editorial (Kaplan H. Safer design.Transfusion 2007 May; 47(5): 758-9) discusses the BEST low tech approach and a high tech approach using radio-frequency microchips, examples of which are in TraQ's technology clearinghouse.

4. The BEST paper can be used to teach how to analyse scientific papers. Besides having an interesting design (multicenter cluster-randomized controlled trial involving short-term and long-term follow-up), the authors discuss multiple weaknesses and strengths of the research and basic statistical concepts such as sample size and statistical power.

5. The paper is a rare example of a negative study that gets published - the stickers had no overall effect on improving compliance with the bedside wristband check. Indeed, the results were slightly worse in the intervention group at the late re-audit stage, 8 weeks after introducing the sticker tag.

The authors speculate that this may have been a chance finding or that the constant reminder may have irritated the nurses and/or added to the complexity, producing the opposite effect to the one intended.

One can speculate that, if one part of a process is stressed, other critical parts may be inadvertently de-emphasized and forgotten, such as forgetting to breath when learning a new exercise for the first time.

Interestingly, the Kaplan editorial notes that procedural strategies are perhaps the least reliable for managing risks, yet are the ones often employed in transfusion and nursing practice where redundancy is typically used to increase reliability, e.g., having a second person check the work of another as done with the 2-person nursing check of patient and donor identification at the bedside prior to transfusion; or the 2-person check done when issuing blood from the transfusion service.

It's the old dictum about catching an error on the first inspection. If you have just seen your colleague perform several checks, you may not be as rigorous when confirming their work.

This study reminds me of other studies that have shown that educational interventions sometimes have no effect on changing behavior. Such results seem counterintuitive because we all want to believe that education will produce a positive effect. The trick is in discovering the right intervention or combination of interventions to motivate the target audience to change.

It's hard to comprehend how a sticker-tag saying "STOP: Check the patient's wristband." could have the reverse effect on a heath provider's performance. Investigating why this occurred could have relevance for similar studies.

If you would care to speculate or discuss further, please leave a comment.

Posted by Blut at 10:29 PM 1 comments

Thursday, April 05, 2007

Blood shortages to be passé?

Hallelujah! Blood shortages may be passé!

Such were the headlines this past week with a flurry of news items about bacterial enzymes that can cut antigen-bearing sugar molecules from the surface of red blood cells. The enzymes can render A and B rbc into group O rbc, producing so-called "universal donor" cells that can be transfused to recipients of any ABO group, providing the rbc are Rh-negative and providing recipients lack unexpected antibodies.

The news was based on this recent publication by Danish researchers:

Was it really news given that the concept has been around for about 25 years? For example:

Editorials back then were similar to today:
Cowart VS. Green coffee beans may solve a blood bank problem. JAMA 1982 Jan 1;247(1):12.

Similar research followed in the 1990s:

Looking back, I think that I first became aware of the possibility of enzymes to cleave ABO blood group antigens in this 1994 paper and accompanying editorial:

These early papers made nice discussion papers for students as they dealt with enzymes from coffee beans, soybeans, and taro (novelty) and helped reinforce the sugars responsible for group A and B antigens.

My joke when teaching ABO blood group chemistry was that no one in the transfusion service ran around asking for a crossmatch for two alpha-D-galactose red cells. <8-)

One problem was that the research dealt with converting B cells into group O red cells (stripping the terminal alpha-D-galactose) and would be more useful if A rbc could be converted using a naturally occurring alpha-N-acetylgalactosaminidase, since group A has a higher frequency in Western Europe and North America.

Another was that the research could not be applied to large scale production despite in vivo studies such as this one:

In a way, the current headlines remind me of the unmet promise of "artificial blood substitutes" (perfluorocarbons and hemoglobin-based oxygen carriers) whose history dates back to the 1960s. We have been waiting a long time!

Many of the news items on the possibility of converting other blood groups to group O include precautions. As noted by Ian Franklin, the national medical and scientific director of the Scottish National Blood Transfusion Service, in the Scotsman:

Quite an understatement by Dr. Franklin. Moreover, the conversion process would need to be cost-effective when applied to large-scale production (millions of blood donors annually).

So, will blood shortages may be passé any time soon? My guess is that this French saying applies:

Keep on donating!

New on TraQ

Posted by Blut at 5:38 PM 1 comments
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Sunday, March 04, 2007

Life as a blood eater

I read with interest "A lifeline of Blood" by Dr. B. Patrick Moore to mark the 60th anniversary of the opening of the first provincial unit of Canada's national blood transfusion service (BTS) in Vancouver, BC on Feb. 3, 1947. "A lifeline of blood" motivated me to write this blog, an updated rendition of a posting I originally wrote for MEDLAB-L in1998 and which later appeared as a 2005 entry in another blog I maintain.

Seeing Dr. Moore's historical note reminded me of the years when I worked as a medical laboratory technologist (aka clinical lab scientist) for Canada's national blood supplier, the Canadian Red Cross Blood Transfusion Service (now Canadian Blood Services) in Winnipeg. The facility was (and is) a combination blood center and transfusion service that performs all crossmatching for the city and small rural hospitals in the province, along the lines of Puget Sound Blood Center in Seattle. It was the mid-60s to late '70s, a time when we performed risky practices and never gave safety a thought.

Back then I knew of Dr. Moore, whom everyone called "Paddy" Moore. To my young eyes (I was practically a child laborer!) he was a "biggie" at National, meaning national headquarters from whence all wisdom seemed to flow.

Those golden days were pre-AIDS. See Pneumocystis Pneumonia -- Los Angeles. MMWR 1981Jun 5; 30(21);1-3 and AIDS timeline - click on each year for details. Syphilis and hepatitis B were the main concerns and we had tests for those, such as they were. I recall testing for the HBsAg (previously the "Australian antigen") using counterimmunoelectropheresis (CIEP).

Talk about a primitive test - you had to pipette just the right amount of liquid agar on a glass plate (an art in itself), wait for it to set, punch out wells, add reagents, incubate, then look for precipitin lines (positives) by holding the glass plate against a black background. I often had difficulty seeing even the positive control!

As an aside, it was an early indiction that my future lay more on the transfusion service side than on the blood centre side. The latter I eventually came to refer to as the "dark side" just to tease my blood centre buddies who worked increasingly with automated instruments. To me they were becoming less and less true blood bankers compared to those who worked in transfusion services and got "down and dirty" with their hands. Eventually, of course, automation made inroads into pretransfusion testing, so we are all now disciples of the dark side.

Back to HbsAg testing by CIEP: Once a colleague came running to me exclaiming, "Pat, help! I just swallowed the positive hep B control!" Frustrated with trying to control the tiny bulb on a tiny pipette (actually just a capillary tube), she had used her mouth to suck up the reagent and dispense it! We called National and their sage advice was to "drink lots and lots of water" and let nature take its course. Of course, the positive control was presumably not infectious as it was only the surface antigen, but who knows what all was in the darn reagent.

Those were also the bad old days in more ways than one. For example, we used no SOPs, if you can imagine. All instructions were passed from trainer to new employee. Talk about standardization - NOT!

Near the end of my time at the Winnipeg BTS (by now I was a senior technologist and trainer) one year I decided on my own to write a procedural and policy manual for the crossmatch laboratory on my holidays. I went to a cottage on a nearby lake for two weeks and in between canoe trips wrote the manual in long-hand (pre-computers days too). All on a volunteer basis without official sanction, and, of course, they used the manual.

Having recently gotten married, my husband thought I was nuts. But he soon grew to understood that the organization was family and that working for the BTS was getting paid to do something that my colleagues and I loved and was great fun to boot.

One of my fondest memories from my Red Cross days was how we used to "shuck" (pour out) blood clots from 100s of donor specimens into kidney dishes before preparing 5% saline suspensions for red cell testing. All the while smoking and drinking coffee, of course. Time was a factor and those clots got tossed with wild abandon - it was the start of what could be a very long day depending on the clinic size. We worked until all blood was tested and sorted (put into inventory), no matter how long that took. For the 1000+ donor clinics held on the day after New Year's Day that could be from 07:00 to 23:00 hrs. No union to influence working hours in those days, either.

But I digress. To start each day we would shuck like crazy until the kidney dishes were full. Blood would splatter everywhere, including all over us, our smokes and coffee cups. No gloves, of course, only white lab coats that we wore everywhere including into the lunch room. My most vivid memory from those days is the taste of blood on my cigarette filter (I gave up the cancer-emphysema sticks in 1987). The blood tasted awful, probably more so as I'm a vegetarian.

The second most vivid memory is of bloody finger streaks on the back of everyone's lab coat (after all, techs need to keep their hands clean and buttocks are as good a place to wipe as any). Some of us were regular Picassos!

When hepatitis B testing was instituted at the blood centre (during my years there we went through counterimmunoelectropheresis, reverse passive hemagglutination, and radioimmune diffusion, all now considered prehistoric), one year all lab staff were tested for both HBsAg and anti-HBs. Of the 20 or so technologists none were positive for HBsAg and only one was anti-HBs positive.

Of course, the BTS was testing healthy blood donors for hepatitis and Canada had a relatively low prevalence rate. Mind you, some of the specimens did test positive, and perhaps some of those made their way to my cigarette filters. Also, in the 1960s we bled donors from Manitoba's two penitentiaries. Indeed, once the rate of HBsAg in jails became known, prisoners were dropped as donor sources.

In retrospect, based on my experience working at the Red Cross BTS in the pre-AIDS days, I view the risk of contracting hepatitis and other blood-borne agents from lab-related activities as being low but certainly not zero. Consider that there were two technologists in the neigbouring province of Saskatchewan who contracted hepatitis B and died from mouth pipetting positive controls in the chemistry lab. We in the blood centres had luck on our side.Baruch Blumberg , awarded a Nobel Prize in 1976 for his discovery of HBsAg, tells the story of how his laboratory technologist came down with hepatitis B before they knew what the Australian antigen was.

Even given that the risk of contracting a blood-borne disease in a blood centre laboratory is low, personally, I would not want to play Russian roulette with a million-bullet gun cartridge containing only one bullet. Sooner or later, someone gets the bullet. The low risk may apply to all the risks that we try to prevent by using universal precautions, especially if the causative organism (unlike HBV) does not survive well on inanimate surfaces such as counter tops.

Today's students and younger lab professionals are astounded at the practices of smoking, mouth pipetting, etc., in the laboratory. In retrospect, even this vegetarian, once blood eater, finds them surreal.

It's hard to realize that when I first joined Canada's national blood transfusion service it was less than 20 years old. A Yikes! thought but somehow it puts everything in perspective.

Cheers, Pat 
Posted by Blut at 6:00 PM 1 comments
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