Assessment of physicians in training's knowledge of transfusion medicine at a university hospital

Abstract

Objective

To evaluate the basic knowledge of transfusion medicine of medical residents who prescribe blood product transfusion.

Material and methods

We evaluated medical residents’ knowledge of transfusion medicine using multiple-choice questions.

Results

We evaluated a total of 186 residents from different departments. The mean score was 47.2 (0–100). The department with the highest score was Hematology (61.5). First-year residents achieved a score of 48.4, a score that was greater than those of subsequent years (44.7). Those who had read a practical guide on transfusion medicine obtained a better mean score than those who had not (55.4 vs. 44.6). No association was found between the mean score and the hours of transfusion medicine classes received during undergraduate training. The topic with the lowest score was related to red blood cell transfusion and fresh frozen plasma in emergency situations (7.5).

Conclusion

The results of this study show a general lack of knowledge on transfusion medicine; therefore, we believe it is important to increase the number of topics related to this subject in undergraduate and graduate classes.

Introduction

Transfusion therapy is one of the greatest achievements of modern medicine. The benefits of blood transfusion are real and the lives of patients with various disorders depend on its use to reduce mortality, prolong life, and improve quality of life.¹

Blood transfusion is one of the five most excessively used medical procedures.² It has become a routine therapeutic procedure despite the availability of cheaper and safer alternatives.³ However, inadequate use of transfusion in hospital settings has been frequently reported. This could be a reflection of a low level of knowledge on transfusion medicine.⁴

In Mexico, 74.4% of red blood cell transfusions, which is the most frequently used blood product, are unjustified.⁵ On the other hand, studies carried out in the United States report that academic programs in medical schools related to transfusion medicine are insufficient. Similar findings have been reported with regard to residencies of different medical specialties.⁴ In other words, medical curriculums do not include transfusion medicine as a learning unit. This is because it is felt that the knowledge necessary to perform transfusions can be acquired from clinical experience instead of programmed education.⁶

Medical residents’ knowledge of transfusion medicine in hospitals has been determined using multiple choice exams that include essential topics of transfusion medicine.⁷ In the “Dr. José Eleuterio González” University Hospital, this evaluation has not been carried out. It is necessary to apply an objective tool that demonstrates the knowledge of transfusion medicine in graduate students. Our objective was to evaluate the basic knowledge of transfusion medicine of medical residents who prescribe blood products.

Material and methods

We carried out a descriptive observational cross-sectional study at the “Dr. José Eleuterio González” University Hospital in Monterrey, Mexico to evaluate the knowledge of transfusion medicine using multicenter studies performed in the United States as a reference.^8,9 A 26-item multiple-choice questionnaire was used for this evaluation. Also, demographic data of the participants was collected. The instrument used was reviewed by clinical pathology professors who are members of the Blood Transfusion Committee. Calculations were based on a score of 100, obtained from 26 items, which was the maximum number of questions (3.85 points for each correct answer).

Residents were distributed according to specialty program and postgraduate year; subsequently, departments were chosen according to the use of transfusion in adult patients. Before applying the instrument, approval in writing was obtained from each department. Residents from different areas who prescribe blood transfusions in adult patients were included. Residents who perform blood transfusions in pediatric patients, who do not prescribe transfusions, who were not rotating in the hospital, and who did not want to participate were excluded. In order to reduce the bias in the study, clinical pathology residents were excluded because of their participation in the application of the evaluations. Information regarding the department where they worked, the postgraduate year, previous knowledge of a practical guide of transfusion medicine, the degree of perception of knowledge in the area, and hours of learning related to the topic during undergraduate and graduate classes was also collected.

Statistical analysis

The information obtained was analyzed using SPSS version 20 for Windows. Descriptive statistics were used for numerical variables as a measure of central tendencies and dispersions. Percentages and frequencies were calculated for categorical variables to describe the demographic characteristics of the participants. Means were calculated for each participant, service, year, and topic; ANOVA was used to calculate the statistical differences of these variables. A P value less than 0.05 was considered statistically significant.

Results

Of the 17 services invited to participate in the study, 14 authorized application of the questionnaire. A total of 186 residents from clinical and surgical areas were evaluated. The greatest number of residents was from first and second speciality years, 31.2% in each of these groups; third speciality year was 23.7% and fourth year or higher was 14%.

When asked if they had previous knowledge of a practical guide in blood product transfusion, only 55.4% answered affirmatively. With regard to self-perception of knowledge of transfusion medicine, 69.2% classified it as intermediate. The rest described it as scarce and advanced at 20.5% and 10.3%, respectively.

Regarding hours of transfusion medicine classes in medical school, 46.2% mentioned having received 3–4 h of classes, 45.7% reported 1–2 h, and the rest 0 h. Regarding hours of transfusion medicine classes during residency, 30.6% mentioned having received 3–4 h of classes, 39.2% reported 1–2 h, and the rest 0 h.

Assessment results

The mean global score was 47.2, with a standard deviation of 10. Inter-individual scores ranged from 19.2 to 73.1. Scores ≤42.3 were found in the 25th percentile, scores from 42.4 to 53.7 were found in the 50th percentile, and scores ≥53.8 were found in the 75th percentile. According to department, the highest scores were those of hematology (61.5), anesthesiology (53.8), and nephrology (53.1), (Table 1). The highest individual scores were those of residents from anesthesiology (73.1), hematology (69.2), and internal medicine (69.2). The mean of subspecialties was higher (49.8) than that of specialties (46.6), although this was not statistically significant (P = 0.08). Regarding scores according to postgraduate year, residents from the first, second, and third year obtained scores of 48.4, 47.2, and 47.1, respectively. First-year residents did better than subsequent years (Table 2). This downward trend in the mean score in subsequent years of practice was not statistically significant (P = 0.476).

Table 1.

Mean assessment score by department (n = 186).

Specialty	n (%)	Mean	SD
Anesthesiology	21 (11.3)	53.8	8.6
General surgery	22 (11.8)	40.7	7.5
Gynecology and obstetrics	12 (6.5)	36.9	6.0
Internal medicine	54 (29)	48.8	10.3
Neurosurgery	8 (4.3)	38.5	7.1
Orthopedics and traumatology	16 (8.6)	46.2	9.2
Otorhinolaryngology, head and neck surgery	7 (3.8)	48.4	9.9
Urology	9 (4.8)	50.0	5.4
Mean score of specialties^*	149 (80.1)	46.6	10.1
Subspecialties
Plastic and reconstructive surgery	12 (6.5)	46.8	6.3
Gastroenterology and digestive endoscopy	6 (3.2)	49.4	8.6
Clinical hematology	6 (3.2)	61.5	4.9
Nephrology	5 (2.7)	53.1	6.3
Neurology	2 (1.1)	51.9	2.7
Oncology	6 (3.2)	41.0	10.8
Mean score of subspecialties^*	37 (19.9)	49.8	9.3

SD: standard deviation.

*

P = 0.08.

Table 2.

Correlation between survey results and mean assessment scores (n = 186).

Postgraduate year	n (%)	Mean	SD	P value
1	58 (31.2)	48.4	9.3
2	58 (31.2)	47.2	10.6
3	44 (23.7)	47.1	10.4
≥4	26 (14.0)	44.7	9.3	0.476
Previous knowledge of a practical guide in transfusional medicine
Yes	103 (55.4)	49.4	9.6
No	83 (44.6)	44.4	9.8	0.001
Level of self-perception of knowledge in transfusional medicine
Scarce	38 (20.5)	45.5	7.4
Intermediate	128 (69.2)	47.1	10.1
Advanced	19 (10.3)	51.4	12.7	0.109

SD: standard deviation.

≥4: 4th, 5th and 6th year residents.

A relationship between the score and previous knowledge of a practical guide of transfusion medicine was seen. Those who had previously read the guide had a mean score of 49.4, while those who had not had a mean of 44.4 (P = 0.001). There was also a correlation between the main and self-perception of knowledge of transfusion medicine. Those who described it as scarce had a mean of 45.5, those who considered themselves intermediate had a score of 47.1 and those who felt they had advanced knowledge had a score of 51.4; however, this was not statistically significant (P = 0.109).

No association was found between the mean score and hours of transfusion medicine classes received during undergraduate training (Table 3). In contrast with hours of transfusion medicine classes during residency, those who reported not having received any type of training in this area had a mean that was lower than those who reported 3–4 h (45 vs. 48.7); this was not statistically significant (P = 0.08).

Table 3.

Score according to hours of class in transfusional medicine during undergradute and posgraduate education.

	Undergraduate			Posgraduate^*
Hours	n (%)	Mean	SD	n (%)	Mean	SD
0	15 (8.1)	47.2	9.9	56 (30.1)	45.0	9.0
1–2	85 (45.7)	47.6	10.4	73 (39.2)	47.7	9.5
3–4	86 (46.2)	46.8	9.7	57 (30.6)	48.7	11.2
Total	186 (100)	47.2	10.0	186 (100)	47.2	10.0

SD: standard deviation.

*

P value = 0.118.

The topics that had the highest averages were warfarin reversal, infectious disease risk related to transfusion, and dose–response to red blood cell transfusion. The topics with the lowest scores were those regarding transfusion of red blood cells and fresh frozen plasma in emergency situations, indications for irradiation of blood products and diagnosis and management of an allergic reaction (Table 4).

Table 4.

Score according to topic.

Topic	Mean	SD
Acute hemolytic reaction	47.6	20.6
Importance of correct identification of samples	26.9	44.5
Notification of a transfusion reaction	64.5	48.0
Allergic reaction	24.7	33.4
RBC transfusion in ACS	33.3	47.3
Dose response to RBC	82.3	38.3
Prophylactic transfusion of PLT in surgical patients	57.0	49.6
Transfusion of RBC and FFP in emergency situation	7.5	26.5
Massive transfusion	33.3	47.3
RBC transfusion in chronic anemia	74.7	43.6
RBC transfusion in acute anemia	37.1	48.4
TACO	51.3	39.1
Prophylactic transfusion of FFP	66.7	47.3
Prophylactic transfusion of PLT	37.1	48.4
Irradiation of blood products	16.7	37.4
Infectious disease risk related to transfusion	87.6	33.0
Wafarin reversal	88.2	32.4
TRALI	38.4	35.5

*Total score based on a scale of 100.

SD: standard deviation; RBC: red blood cells; ACS: acute coronary syndrome; PLT: platelet concentrates; FFP: fresh frozen plasma; TACO: transfusion-associated circulatory overload; TRALI: transfusion-related acute lung injury.

Discussion

The “Dr. José Eleuterio González” University Hospital is part of the School of Medicine and has both undergraduate and postgraduate areas. The undergraduate area has an academic program in Clinical Pathology and Internal Medicine, where basic topics in transfusion medicine are reviewed. However, not all the residents in the hospital are graduates of our School of Medicine. Consequently, we have no complete knowledge of their curriculum. This study was carried out to assess medical residents’ basic knowledge of transfusion medicine.

According to the departments that participated in the study, the Hematology Service had the highest score, a finding that is similar to a previous study.¹⁰ This could be because physicians from this service receive additional training in transfusion medicine and most of their activities are related to transfusion. On the other hand, the department that scored the lowest was Gynecology, this could be related to limited use of transfusion as a therapeutic option, since it represents approximately 6% of all transfusions in this center, according to a study conducted at “Dr. José Eleuterio González” University Hospital.¹¹

Regarding the score and the year of residency, it is important to point out that knowledge decreased in subsequent years, similar to reports published in the literature. Residents in subsequent years had lower scores than those in the first, second, and third year.^8,10,12 This could be because these physicians enter areas that have less contact with transfusion medicine as they advance in their academic training.

In a literature search, we did not find publications that correlate scores and previous knowledge of a practical guide of transfusion medicine. In this study, the mean score obtained by those who had read such a practical guide was greater than those who had not. Furthermore, we observed an association between the score and the degree of self-perception of transfusion medicine knowledge. Those who described their knowledge as advanced had a higher mean score than those who reported very little or intermediate knowledge, similar to that reported by Haspel et al.⁸

In contrast with previous publications that found better results among those who took classes in transfusion medicine during undergraduate education, there was no association between scores and hours of classes on this topic during medical school in this study. According to the scores obtained with regard to hours of transfusion medicine classes during residency, 30.1% responded that they had no training in this area and 11.7% mentioned receiving 3–4 h of classes; these residents had a score of 45 and 48.7, respectively. The correlation between performance on the assessment and a formal education of 3–4 h in transfusion medicine during residency was greater than those who did not receive any type of training. This is similar to a previous report.⁸

Regarding topics in transfusion medicine, the highest scores were in warfarin reversal (88.2), risk of infectious diseases due to transfusion (87.6), and dose–response to red blood cells transfusion (82.3).⁶ Topics with the lowest scores were transfusion of packed red blood cells and fresh frozen plasma in emergency situations (7.5), indications for irradiation of blood products (16.7), and diagnosis and management of an allergic reaction (24.7), findings similar to that of previous publications.^6,8 These areas of knowledge should be considered important for intervention.

The results of this study reinforce previous publications that suggest the need for a greater number of programs on transfusion medicine for medical students, graduates, residents, and those involved in decision-making.^6–14 Some studies have implemented a variety of educational interventions, such as Kaur et al., who evaluated physicians’ basic knowledge of the practice of transfusion medicine. Participants in this study received training in addition to a pre- and post-training questionnaire. As a result, there was an increase in the mean score after training. In a similar manner, Rebel et al. published the results of a structured clinical rotation in hematology and transfusion medicine for anesthesiology residents where participants were evaluated pre- and post-rotation. A better performance was found in the post-rotation evaluation.¹⁴ However, the effects of these interventions could be short-lived, which is why a combination of strategies is probably more effective, especially if they are performed continuously.

In this study, there was no comparison of transfusion medicine knowledge among attending physicians and residents, because a situational diagnostic is required in order to identify areas of opportunity in the current curricular plan, so it is suggested to consider the affiliated physicians’ evaluation in posterior phases.

A limitation of this study is that the instrument applied was not validated. However, the selection of topics was based on previous literature and each question had a bibliographic basis. Also, the instrument was reviewed by faculty from the Clinical Pathology Department who are members of a blood transfusion committee. We also took into consideration the study carried out in our country that reported a high rate of unjustified transfusions.⁵

Physicians who prescribe blood transfusions to pediatric patients were not included in the present report since the indications, threshold, and clinical data differ from adults and different questions would have to be made for this population. In order to reduce bias in the study, Clinical Pathology residents were excluded because of their participation in the application of the evaluations.

Conclusion

To ensure transfusion safety for the receptor, adequate knowledge of blood product transfusion, identification and adverse reactions by the physician is essential. The results of the study show that there is a generalized deficit in transfusion medicine knowledge and it suggests the need for educational interventions for residents who prescribe blood transfusion. Emphasis should be placed on areas with more deficits, such as use of packed red blood cells and frozen fresh plasma in emergency situations, indications for blood product irradiation and massive transfusion.

We recommend increasing the number of topics related to transfusion medicine in undergraduate and postgraduate academic programs and suggest extending these studies in other hospitals to evaluate the use of blood products. Also, the Transfusion Committee at the hospital should increase its periodical audits on transfusion practices and implement feedback strategies to improve blood transfusion surveillance.

Funding

No financial support was provided.

Conflict of interest

The authors have no conflicts of interest to declare.