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Musings by Malcolm Needs: Regrets, Concerns, Challenges

Musings by Malcolm Needs: Regrets, concerns, challenges

This blog is a follow-up to Malcolm's earlier ones and presents his musings on regrets, concerns. and challenges for the profession going forward. 

MALCOLM'S MUSINGS 

AUTOMATION 

With the advent of more reliable automation, the skill mix of hospital laboratories has changed drastically in the last few years, and fewer and fewer Biomedical Scientists are being employed, whilst many posts are now filled with laboratory assistants who can “feed” the machines, but who are unable to interpret results, especially if these results are atypical. This has resulted in a greater number of “easy” samples being sent to the reference laboratories that would, in days’ bygone, have been resolved at the hospitals. This, I hasten to add, is not the fault of the staff in the laboratories, but is a result of the decisions being made at a much higher level of management. One hesitates to think how some of these hospital laboratories would cope with the number of patients that would be expected after a major incident.

Nonetheless, two huge advantages of automation over manual techniques are
  • Ability to have positive sample identification
  • Automation 'reads the tests' in the same way whatever the time of day or night (in other words, the 'eyes' of the automation do not get 'tired').
LEAN 

As you will be aware, the UK, like many other countries, is going through a recession. As a result, budgets are being cut (some drastically). At the same time, laboratories have been introduced to the concept of LEAN working. Without a doubt, there have been improvements in the way laboratories have been run, with less waste but, also without doubt, there is a time and a place for everything. Let me explain.

Whilst I appreciate that LEAN has its place, and has improved the wastage figures in most laboratories, it cannot be regarded as 'the be all and end all' or 'the panacea for all ills' in all laboratories. Indeed, it is possible to 'over LEAN' a laboratory, in particular a Red Cell Reference Laboratory, where there is a need to have the freedom to select suitable reagents for the investigation to get accurate results. Such a choice, in experienced hands, could actually prove less wasteful than sticking to the LEAN dogma and using the reagents dictated by this dogma.  

The blind introduction of LEAN into all aspects of all laboratories may, under certain circumstances, have exactly the opposite effects than those desired.
 
In a way, what I am trying to get across is the fact that, when I started out, Health and Safety in the laboratory tended to stop at putting on a laboratory coat (certainly smoking was allowed, or, rather, tolerated) and so we needed to 'pull our socks up' in this area, which we did. However, it got to the stage at one point where it became almost impossible to undertake the day's work without breaking some rule instigated by the 'H&S police'.
 
Similarly, when I started out, there was no such department as Quality (although there was certainly quality in the work performed). Now, we are being 'led by the nose' by both the Quality Department and various accrediting agencies. Most disagree with each other, leading to copious congratulations from one for some technique, and a stern non-conformance from another, again, making some of our work almost impossible.
 
An improvement in both H&S and Quality was, without doubt, desperately required, but both ended up going 'well over the top'. My comment about LEAN is that there is a danger that the same may happen, and that there is already evidence that precisely this has happened.
 
STANDARDISATION 

Without trying to be either provocative or insulting, and within reason, the Processing, Testing and Issuing of units of blood and blood components is the same for one unit as it is for the other hundreds that are collected day after day, throughout the country. On the other hand, the samples we receive for reference work are patient led in terms of what tests are required, and what advice needs to be included on the reports. Certainly, some samples are very similar to other samples, such as those antenatal reference samples with anti-D in a pregnant woman, all of which would be dealt with in an identical way, resulting in reports that vary only a little.
 
However, other commonly seen reference samples, such as those from patients with a positive DAT or with multiple antibodies, cannot, and should not, be treated in exactly the same way as one another, and require a report with more detail than available “canned comments” that can be added with the stroke of one or two keys on the keyboard. 

Herein lies the problem. In an effort to streamline the way the laboratories work, and to standardise the work, a “one size fits all” plan of campaign has been forced onto all of the reference laboratories within NHSBT, with little thought to the differences seen in the kind and number of hospitals served by the laboratories (e.g. the large London Teaching Hospitals that attract patients with rare or, at least, unusual conditions) and the mixture of ethnic concentrations in their various catchment areas. At the same time, the laboratories are expected to work extended hours, with the same number of staff (or with a minimal increase).

It was forecast that this would bring down the morale of the staff, that people, including those with the most experience, would start to leave and mistakes would be made. Sadly, this forecast has proved to be true, but, in addition, because the staff are reluctant to perform extensive testing beyond that which is prescribed by the LEAN process, more and more samples are being sent on to the IBGRL (in essence, the reference laboratory for the reference laboratories of NHSBT) that they are becoming overwhelmed and their own turnaround times are beginning to become unacceptable.

It is not all doom and gloom, though! Indeed, far from it.

RBC GENOTYPING 

NHSBT Red Cell Immunohaematology Laboratories are (finally) being dragged kicking and screaming into the 20th century (Yes, I do mean the 20th C!) and are now capable of performing genotyping (something our Histopathology and Immunohaematology colleagues have been doing for years with HLA testing). Granted, the genotyping technology being used has been described as “quick and dirty” by some. More specifically, the molecular technology used in the RCI laboratories is able to detect either the presence or absence of a particular (known) gene at a locus, whereas that used at the IBGRL can be used for complete gene sequencing (e.g. to detect and specify a Partial RHD gene). But, until recently, any molecular techniques looking at predicting red cell antigen expression had to be sent to the IBGRL, and so this is a vast improvement. 

In addition, and from the antibody identification side, we are also beginning to use recombinant blood group proteins (as described to me primarily by Axel Seltsam in Switzerland (photo), on a course on which we were both lecturing), and I think these will really come into their own in the next few years. 

PAT'S MUSINGS

Based on this blog, Malcolm's third, I wrote most of my comments in a separate personal TM blog, Four Strong Winds (Further Reading). That blog dealt with automation, LEAN, standardization, and blood group genotyping. Of course, my views are not necessarily Malcolm's but it was fun to feed off  his musings and offer my takes on his '4 strong winds'. 

About Malcolm's mention of recombinant blood group proteins, I must admit this development had not made it into my brain, maybe because to push its way in, something would need to be jettisoned. Perhaps all that passé blood group serology hogs my neuronal connections and resists being tossed out? To my knowledge no routine transfusion lab is anywhere close to using recombinant blood group proteins. When that becomes a reality, it will be fascinating to see diagnostic companies pivot to dissing reagent red cells as so....20th C. 

Regardless, I searched PubMed and found papers on recombinant blood group proteins dating back 10 years. See Seltsam (Further Reading). 

Comments are most welcome. No matter where you live and work, I hope you have enjoyed Malcolm's blogs outlining his UK experiences over a long career. Please add to the record of what it was (or is) like to work as a transfusion professional, perhaps contrasting your experiences with Malcolm's. Can you add to the discussion on  automation, LEAN, standardization, and blood group genotyping?  If uncomfortable with commenting using the web interface, if you write webmaster@transfusion.ca, she can add your comments as 'Anonymous' or attribute them, if you prefer.

Further Reading
TM blog: Four strong winds (Musings on trends identified by Malcolm Needs' 3rd CSTM blog)
Seltsam papers:

Comments

Comments
Pat Letendre
Thanks for the feedback, Tom. Much appreciated. As an aside, kudos for these blogs is all due to CSTM. Back in 2015 it's then President, Dr. Gwen Clarke, made me an offer I couldn't refuse. <big grin>

I'll comment on two of your points:

1. COLLABORATION
Tom: 'The enthusiasm for transfusion medicine is there but it needs fostering and encouragement with collaboration required (personal opinion) between those societies responsible for training and knowledge dissemination (IBMS,BBTS,NHSBT,NSHCS to name a few) together we are stronger.'

I could not agree more. For example, in Canada the CSMLS <http://csmls.org/> sets the exams that medical laboratory technologists must write in order to practice in clinical labs. It's the same exam for general certification to practice in 5 lab disciplines, including transfusion science.

To my knowledge, no cooperation exists between the CSMLS and the voice of transfusion medicine in Canada, namely the CSTM. CSTM members would be perfect to help set exam content that reflects the knowledge and competencies required to work in today's transfusion service and blood supplier laboratories. As to setting exam questions, granted help would be needed from educators about how to construct valid questions and validate them.

Yet, recently CSMLS decided that instructors in educational facilities could not serve as exam panel members. Presumably, CSMLS thinks that instructors setting national exams might 'teach to the exams' with their own students, giving them an unfair advantage. From knowing instructors who once served on the panel, this could not be further from the truth.

What's needed in education and training is a combination of educators and working technologists,whether on the bench or in supervisory roles. The CSTM, as a national body, would be ideal collaborator with CSMLS. The main benefit is, being national, CSTM could help ensure that regional biases and practices did not influence exam questions.

Fact is, many educators and practitioners have tunnel vision and, worse, a silo mentality that looks inward and resists sharing information and resources with other people. Looking inward never results in improvements and innovation. And to students, who may end up working who knows where, it's akin to a kiss of death on their ability to adapt to new environments.

As a lifelong educator one of the things I hope I was true to was to give students the 'big picture' and explain that how things are done in our institution is not how they are done elsewhere. This fits with the view that a little knowledge is always a dangerous thing.

On the bigger picture, educational institutions across Canada could tap into CSTM webinars and regional CE days so students could be exposed to current issues. Indeed, CSTM could tailor some presentations to student trainees.

As Tom mentioned, collaboration between organizations can foster, encourage, and improve transfusion education and practice in all areas.

2. PRECEDENT FALLACY
Tom: Lean has been great for '...getting rid of some of those crazy things that we've done for ages (like logging samples in on 3 computer systems) because "so and so used to do it like that, so that's why we've always done it like that'.

By 'precedent' I mean this one, which reflects Tom's view, from Cambridge Dictionary: "The way that something has been done in the past that therefore shows that it is the correct way."
http://dictionary.cambridge.org/dictionary/english/precedent

Boy, does Tom's view resonate with me. So much of what transfusion professionals teach and promote is based on our teachers and the Grand Poobahs who ruled the roost at our facilities for years. Such historical precedents and orthodoxy need to be resisted at every opportunity. Unfortunately, many folks do not even realize the subtle effects of who taught them in shaping their views.

Thanks, again, Tom, for insightful comments on Malcolm's blog.
2/21/2017 2:34:47 PM

Tom Bullock
Another great musing from Malcolm, and on the whole I agree with most of his points regarding loss of knowledge and skills. As I see it, due to a combination of lack of funding or time for training, increased automation, unclear training routes for different grades of staff, which are constantly under review or changing junior staff either don't know what the best route(s) for them are or where they will get the time (or the money) to pay for this training. The enthusiasm for transfusion medicine is there but it needs fostering and encouragement with collaboration required (personal opinion) between those societies responsible for training and knowledge dissemination (IBMS,BBTS,NHSBT,NSHCS to name a few) together we are stronger. The use of LEAN methodology in laboratories is suitable for many processes and can help with the increased amount of regulatory compliance that we currently face. LEAN is a great problem solving tool, but it should not define how we should work all problems out. There's a time and a place. It's been great for standardising some processes, freeing up time, (and money 😜) and getting rid of some of those crazy things that we've done for ages (like logging samples in on 3 computer systems) because "so and so used to do it like that, so that's why we've always done it like that". I've seen colleagues look at why and how we do things and really question if we are doing the best for our patients, and that can't be a bad thing as patients are at the heart of everything we do.
New tests? Genotyping is great, but again has its limitations. Mass genotyping of donors for common polymorphic antigens (and some rares prevalent in BAME communities) would be great in the future, and genotyping for transfusion dependent patients is a good start. I can't see us moving away from ABO monoclonal antibodies any time soon, due to the complexities of the ABO blood group system and ease and cheap cost of the current reagents.
Having been lucky enough to work with Axel Seltsam and the recombinant proteins as part of my MSc project I can see the application of these in reference laboratories, and they are being used now within IBGRL and RCI within NHSBT. I'd love to see a one bead, one antigen assay like Luminex eventually, however the complexities of Rh for example make it difficult to produce the same protein in its original conformation in soluble form to subsequently affix to a bead. So perhaps something else will come along in due course?
Cheers to Malcolm for another great post, and to Pat and CSTM for publishing them!
2/20/2017 5:10:11 PM

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