Education, training and competency assessment for intraoperative cell salvage.
Abstract: The use of Intraoperative Cell Salvage (ICS) is an important facet in establishing the recommendations of Better Blood Transfusion (DH 2007). Training in ICS often varies and has been identified as a challenge in the establishment of the routine use of ICS (UKCSAG 2007a). To help address this, the UK Cell Salvage Action Group, has developed a number of tools to assist in the delivery of both theory and practical elements of ICS training. The aim of this work is to provide standardised educational materials to support ICS training in hospitals throughout the UK.

KEYWORDS Intraoperative Cell Salvage / Competency Assessment / Education
Authors: Grainger, Hannah
Jones, Joan
McGee, Danny
Pub Date: 12/01/2008
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2008 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Dec, 2008 Source Volume: 18 Source Issue: 12
Accession Number: 200343280
Full Text: Introduction

Allogeneic (donor) blood is a valuable but limited resource which is increasingly expensive, and although potentially life saving, is not without risks (for example, wrong blood incidents, transmission of infection and immunosuppression).

Management of the supply of allogeneic (donor) red cells is an important issue in the UK. The perceived theoretical risk of the transmission of vCJD through blood transfusion has resulted in changes to the donor selection criteria, specifically, individuals who have received or think they may have received a transfusion after 1 January 1980 are no longer eligible to donate blood.

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This measure and other restrictions on a donors eligibility to donate, have reduced the already diminishing blood donor population. The introduction of a test for vCJD in the future could impact on the willingness of donors to donate. It is possible that significant blood shortages may result in the restriction of transfusion to treatment of active major bleeding, emergency surgery and life-threatening anaemia.

The use of ICS as an alternative to allogeneic blood, is now a well established technique in many hospitals throughout the UK and its use is supported through the recommendations of the Health Service Circular--Better Blood Transfusion--Safe and Appropriate Use of Blood (DH 2007). However, the development of ICS services often fails where there is a lack of a robust infrastructure to support the training of staff.

The UK Cell Salvage Action Group, a subgroup of the NHS Blood and Transplant Appropriate Use of Blood Group, was established to help support the wider implementation of ICS as an alternative to donor blood, and to facilitate a UK approach in regards to its use.

Competency assessment

To help address concerns over training and the lack of competency assessments for operators of ICS equipment, the UK Cell Salvage Action Group developed an Intraoperative Cell Salvage Competency Assessment Workbook (UKCSAG 2007b) (Figure 1). The workbook can be downloaded from the Better Blood Transfusion Toolkit website at www.transfusionguidelines.org.uk

The competency assessment workbook is linked to the National Occupational Standards (NOS) for cell salvage, which are available on the Skills for Health website (www.skillsforhealth.org.uk). Skills for Health has developed the NOS, for ICS and many other areas of clinical practice, to outline what individuals need to do, what they need to know and which skills they need, in order to carry out an activity. The NOS for ICS are outlined in Table 1.

The Knowledge and Skills Framework (KSF), referred to in the NOS, is a key part of the NHS Agenda for Change pay system and applies to all staff employed on Agenda for Change terms and conditions. KSF is an organisational tool for describing the knowledge and skills that staff need to apply at work in order to deliver high quality services.

The aim is that all staff should:

* have clear and consistent development objectives

* be helped to develop in such a way that they can apply the knowledge and skills appropriate to their level of responsibility

* be helped to identify and develop knowledge and skills that will support their career progression.

The NOS for cell salvage are linked to the KSF dimension:

Health and Wellbeing 7--Interventions and treatments relating to the structure and function of physiological and psychological systems.

The Health Professions Council (HPC) and the Nursing and Midwifery Council (NMC) keep a register of health professionals who meet their standards for training, professional skills, behaviour and health. When re-registering with these bodies each registrant must sign a declaration confirming that they, among other things:

* continue to meet the standards of proficiency for the safe and effective practice of the profession

* continue to meet the standards for continuing professional development.

As such, the ICS competency assessments provide not only a measure of quality control for organisations delivering a cell salvage service, but evidence of the individual's continuing professional development.

The ICS competency assessments are designed to allow the learner flexibility to achieve competency within the level of their professional responsibility. The theory and practical elements of training are outlined, with an indication of a number of ways in which training can be delivered. The competencies recommend that supervised training is undertaken for as long as the trainer feels necessary and that this is followed by three correctly performed observation assessments prior to the final observation and sign off.

The ICS competency assessment workbook includes a case log and a reflective log, both of which can be maintained following successful completion of the competency assessments. Learners can also include 'additional evidence' to support the sign off of their competency assessments.

The competency assessments also provide guidance on maintaining competency, competency assessment when more than one type of cell salvage device is in use within a department, recommendations on when update training should be carried out and the frequency of competency assessment.

The ICS Competency Assessments are endorsed by the Association for Perioperative Practice, the British Blood Transfusion Society and The Royal College of Anaesthetists.

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ICS Training

Staff involved in the operation of ICS equipment should be trained to the level at which they are expected to operate. Training should include both theory and practical elements which meet the requirements of the ICS competency assessments and the level of the individuals responsibilities. However, training for ICS is often varied and can be difficult to achieve where there is a lack of infrastructure to support learners.

In a survey carried out in 2007 by the UK Cell Salvage Action Group (UKCSAG 2007a), 18% of hospitals using ICS outlined training as a challenge encountered when implementing ICS (Figure 2).

At present there are a number of options available to support education and training in ICS:

Manufacturers training

Each company will offer and deliver both theory and practical training specific to their equipment.

In-house training

Key trainers, trained by the manufacturers deliver theory and practical training within their organisation.

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E-Learning

* www.learncellsalvage.org.uk--this website is specific to cell salvage, providing the learner with an overview of the subject and offering an end of course assessment. This e-learning package provides theory training only and must be accompanied by machine-specific practical training.

* www.learnbloodtransfusion.org.uk--this website covers all areas of transfusion practice and has assessments for each module.

ICS Education Workbook

This provides in-depth theory to assist the learner in the safe and appropriate use of ICS machines and includes elements of self-directed learning. This workbook provides theory training only and must be accompanied by machine-specific practical training.

ICS Competency Assessment Workbook This should be used in conjunction with any or all of the above options to provide a record of the individual's training and assessment.

The ICS Education Workbook

The ICS education workbook (Figure 3) has been produced by the UK Cell Salvage Action Group, whose remit includes helping to standardise educational materials available to support ICS training in hospitals throughout the UK.

The workbook is intended for doctors, operating department practitioners, perfusionists, nurses, midwives, healthcare support workers and all other staff responsible for the set-up and/or running of ICS machines.

The workbook focuses on aspects of ICS use for adult practice only and does not currently cover any specialised requirements for paediatric practice.

The workbook aims to provide the learner with the knowledge necessary to provide safe and appropriate use of ICS machines and disposables. Once completed it can be kept and used as a reference tool. It should be used in conjunction with practical training covering the following skills:

* Set up of machines/disposables

* Processing red cells for re-infusion

* Re-infusion

* Disposal of cell salvage waste

Each section of the workbook follows the same format and contains the following:

* Aims

* Learning Outcomes

* Subheadings for each 'topic'. These will include the body of the text, pictures, and boxes containing information and best practice guidance/cautions

* Documentation (if applicable) .

* Key Points

* Further Reading

* Self Directed Learning section

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An example of a page from the workbook is shown in Figure 4.

The self-directed learning elements of the workbook reinforce the theory component of each section and encourage the learner to identify practice within their organisation. Throughout the workbook, the learner will come across 'Caution' and 'Information and Best Practice' boxes similar to those in Figure 5.

The education workbook may be used as part of a training pathway. A suggested pathway designed to offer comprehensive and flexible learning in the use of ICS and which includes training in safe transfusion practice (www.learnbloodtransfusion.org.uk) is outlined in Figure 6.

The workbook covers the theory aspects of ICS, including the supporting background information. Three sections of the workbook are dedicated to providing this background information:

Basic Blood Facts

This provides a revision of the characteristics and function of blood components and the coagulation cascade. This is followed by a description of allogeneic (donor) blood component therapy, including volume, storage and clinical indications in the surgical setting.

Blood Conservation

Aspects of blood conservation are covered, with an outline of the factors affecting the blood supply, including drivers such as Health Service Circular Better Blood Transfusion--Safe and Appropriate Use of Blood 1.

Haemovigilance

The background information is completed in a section that outlines the strategies for haemovigilance, with brief descriptions of the Serious Hazards of Transfusion (SHOT) and Serious Adverse Blood Reactions and Events (SABRE) systems.

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The remainder of the workbook focuses on ICS, including the practicalities of the technique. This does not however replace the requirement for practical training. The sections that complete the workbook include:

Principles of ICS

This section aims to enable the learner to develop an understanding of the various stages of ICS and the different types of system the learner may come across in their workplace.

Indications and Contraindications

The aim of this section is to highlight the surgical areas where ICS is indicated or may be contraindicated, including discussion and guidance on use of ICS in obstetrics, malignancy and the presence of bowel contamination.

Practicalities of blood collection, processing and reinfusion

Three sections follow which provide detailed information on the practicalities of blood collection, processing and reinfusion. These sections provide detailed information relating to the process, equipment, setup and potential problems at each stage of the procedure. The sections also provide guidance on decisions the operator may need to make during the procedure.

Unloading and discarding

The workbook concludes with a section focusing on the principles of unloading and discarding the ICS disposables. As in other sections of the workbook, the need to adhere to Health and Safety Regulations is highlighted.

In addition to the main chapters of the workbook, a number of appendices provide additional useful information. For example, one appendix is dedicated to the use of ICS in Jehovah's Witness patients, an area of practice that often concerns new users. The information contained in the appendix is taken from a technical fact sheet on the subject (available to download from www.transfusionguidelines.org.uk) which was also developed by the UK Cell Salvage Action Group verified by representatives of the Jehovah's Witness community.

Conclusion

The requirements for appropriate training and competency assessment in ICS and the need for educational materials to support these are being addressed by the UK Cell Salvage Action Group through the development of resources such as the ICS education workbook.

The ICS education workbook is intended to provide the learner with a sound knowledge base before attending/receiving practical teaching on operating the ICS machine. In addition, the workbook will provide the trained operator with a valuable reference tool.

Completion of the education workbook is one of six clear stages of a training pathway (Figure 6) designed to offer the learner comprehensive and flexible training.

Successful implementation and continued delivery of ICS across the UK is greatly dependant upon each organisation developing a sound infrastructure to support not only the training of staff, but the appropriate use, quality control and continuing development of this technique as an alternative to allogeneic blood.

The ICS education workbook along with all other ICS documents mentioned in this article are available for all organisations to download from the Better Blood Transfusion (BBT) Toolkit (www.transfusionguidelines.org.uk).

Task 1

* Explore the autologous blood transfusion techniques that are offered by your department in relation to this key document

Department of Health (2007) Health Service Circular 2007/001: Better Blood Transfusion--Safe and Appropriate Use of Blood

http://www.dh.gov.uk/en/Publicationsa ndstatistics/Lettersandcirculars/Health servicecirculars/DH_080613?IdcServic e=GET_FILE&dID=154794&Rendition= Web

Reflect:

* How has this impacted on your practice?

Notional Learning Hours

1 hour

Knowledge and Skills Dimension

Core 1: Communication

Core 2: Personal and people development

Core 3: Health, Safety and security

Core 4: Service Improvement

Core 5: Quality

HWB2: Assessment and care planning to meet health and wellbeing needs

HWB6: Assessment and treatment planning

HWB7: Interventions and treatments

HWB9: Equipment and devices to meet health and wellbeing needs

HWB10: Products to meet health and wellbeing needs

Task 2

Log into the NHS Scotland better blood transfusion Continuing education web site and complete Level 1 and Level 2 of the on line materials.

http://www.learnbloodtransfusion.org .uk/

Complete the on line introduction to cell salvage.

http://www.transfusionguidelines.org.uk /lcs/index.htm

Notional Learning Hours

Minimum 3 hours

Knowledge and Skills Dimension

Core 1: Communication

Core 2: Personal and people development

Core 3: Health, Safety and security

Core 4: Service Improvement

Core 5: Quality

HWB2: Assessment and care planning to meet health and wellbeing needs

HWB6: Assessment and treatment planning

HWB7: Interventions and treatments

HWB9: Equipment and devices to meet health and wellbeing needs

HWB10: Products to meet health and wellbeing needs

Task 3

Complete the cell salvage competency work book. This can be used as part of your IPR process as well as your CPD. You can download the work book from this link.

UK Cell Salvage Action Group (2007b) Intraoperative Cell Salvage Competency Assessment Workbook Version 2

http://www.transfusionguidelines.org/d ocs/pdfs/bbt-01_intra-op-cell-salvagev2. pdf [Accessed August 2008]

Notional Learning Hours

Will depend on each individual undertaking the competency framework

Knowledge and Skills Dimension

Core 1: Communication

Core 2: Personal and people development

Core 3: Health, Safety and security

Core 4: Service Improvement

Core 5: Quality

HWB2: Assessment and care planning to meet health and wellbeing needs

HWB6: Assessment and treatment planning

HWB7: Interventions and treatments

HWB9: Equipment and devices to meet health and wellbeing needs

HWB10: Products to meet health and wellbeing needs

Task 4

Read the following sections in the Handbook of Transfusion Medicine: 'Pretransfusion and Transfusion Procedures' (Section 2) and 'Clinical Transfusion: Surgery and Critical Illness'/'Planned Surgery' (Section 3) available from: http://www.transfusionguidelines.org.uk /docs/pdfs/htm_edition-4_all-pages.pdf

Reflect on how this has helped to inform your practice

Notional Learning Hours

1 hour for the reflection

Knowledge and Skills Dimension

Core 1: Communication

Core 2: Personal and people development

Core 3: Health, Safety and security

Core 4: Service Improvement

Core 5: Quality

HWB2: Assessment and care planning to meet health and wellbeing needs

HWB6: Assessment and treatment planning

HWB7: Interventions and treatments

HWB9: Equipment and devices to meet health and wellbeing needs

HWB10: Products to meet health and wellbeing needs

References

Department of Health 2007 Health Service Circular 2007/001: Better Blood Transfusion Safe and Appropriate Use of Blood Available from: ww.dh.gov.uk/en/Publicationsandstatistics /Lettersandcirculars/Healthservicecirculars/DH_ 080613?IdcService=GET_FILE&dID=154794&Ren dition=Web [Accessed August 2008]

UK Cell Salvage Action Group 2007a Intraoperative Cell Salvage Survey UK Report Available from: www.transfusionguidelines.org /docs/pdfs/bbt-03_ics-survey-report-2007.pdf [Accessed August 2007]

UK Cell Salvage Action Group 2007b Intraoperative Cell Salvage Competency Assessment Workbook Version 2 www.transfusionguidelines.org/docs/pdfs/bbt01_intra-op-cell-salvage-v2.pdf [Accessed August 2008]

Correspondence address: Hannah Grainger, Welsh Blood Service, Bocam Park, Ffordd Yr Hen Gae, Pencoed, CF35 5LJ

Hannah Grainger

Cell Salvage Co-ordinator, Welsh Blood Service

Joan Jones

Cell Salvage Co-ordinator, Welsh Blood Service

Danny McGee

Cell Salvage Co-ordinator, Welsh Blood Service

On behalf of the UK Cell Salvage Action Group
Table 1. National Occupational Standards for ICS

NOS        Description                             KSF    KSF
number                                             Link   Level

HCS-CP17   Collect and process autologous          HWB7   3
           blood intra or post operatively

PCS19      Prepare equipment for intra-operative   HWB7   2
           blood salvage collection

PCS20      Operate equipment for intra-operative   HWB7   2
           blood salvage and collect blood

PCS21      Prepare equipment for processing        HWB7   2
           salvaged blood

PCS22      Operate and monitor equipment for       HWB7   2
           processing salvaged blood and
           complete salvaged blood processing

Figure 2. Challenges encountered when implementing ICS
in Organisations (UKCSAG 2007a)

Unknown                          6%
Training                        18%
N/A                             32%
Other                            7%
Financing the service            9%
Surgeon compliance/acceptance    7%
Staff acceptance/Resistance     21%

Note: Table made from pie chart.
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