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| Knowledge of blood transfusion practices among medical students and residents |
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Roula A Farah1, Aida Mitri2, Hiba El Rahi1, Hind Al Humaidan3, M Hasan Rajab4, Sabri Kemahli4
1 Department of Pediatrics, LAU Medical Center Rizk Hospital, Beirut, Lebanon
2 Department of Pediatrics, Balamand University, Beirut, Lebanon
3 Blood Bank, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
4 College of Medicine Alfaisal University, Riyadh, Saudi Arabia
Click here for correspondence address and email
| Date of Submission | 08-Oct-2021 |
| Date of Decision | 04-Jan-2022 |
| Date of Acceptance | 13-May-2022 |
| Date of Web Publication | 26-Sep-2022 |
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 Abstract | | |
A study was conducted to assess and compare the knowledge of blood transfusion practices among medical students and residents in Lebanese and Saudi medical institutions. The online survey consisted of 26 questions: 4 about personal data and experience with transfusion and 22 about knowledge on transfusion practices in the areas of blood donation and donor selection, production and storage of blood components, selection of appropriate blood components, administration of blood components, transfusion reactions, and complications. One hundred and twenty-six students from Saudi Arabia, 84 students from Lebanon, 31 residents from Saudi Arabia, and 23 residents from Lebanon participated in the survey. There were no significant differences between students' and residents' levels of knowledge. Similarly, there was no difference between the students' level of knowledge in the two countries. The correct responses (48% and 46%, for students and residents, respectively) were below the acceptable limit of 60% for both groups. This reflects the need for more vigorous and well-structured education and training for both students and residents.
Keywords: Medical education, medical students, residents, transfusion medicine, transfusion
How to cite this URL:
Farah RA, Mitri A, El Rahi H, Al Humaidan H, Rajab M H, Kemahli S. Knowledge of blood transfusion practices among medical students and residents. Asian J Transfus Sci [Epub ahead of print] [cited 2023 Mar 23]. Available from: https://www.ajts.org/preprintarticle.asp?id=356861 |
| Introduction | |  |
Blood transfusion is one of the most common procedures performed in hospitals; however, it has been identified as an overused intervention in the Choosing Wisely campaign by eight North American Societies.[1] Several studies have identified the gaps between clinical practice and evidence-based practice, highlighting the need for improvement.[2]
Although blood transfusions are much safer today due to the improvement of pretransfusion tests, transfusions still expose the recipients to a number of risks, such as the transmission of infections (hepatitis B, C, HIV, and others) sepsis, hemolytic reactions, immunomodulation, and circulatory overload.[1]
Ordering the correct blood component according to the needs of the patient, assessing the relevant laboratory results, especially immunohematological tests, and evaluating and managing transfusion reactions and complications are expected from the practicing doctors.
Although educational lectures are provided on transfusion medicine topics in most medical school curricula, several studies conducted in different countries have shown that the knowledge of physicians on various aspects of transfusion practice is not sufficient.[1],[3],[4]
We aimed to identify and compare the level of current knowledge and practices of medical students and residents in various medical schools in the Middle East region about transfusion medicine to identify the gaps in medical education. This issue has become increasingly important nowadays after the COVID-19 pandemic and the series of lockdowns in various countries, leading to a scarcity of blood donations.[5]
| Materials and Methods | | |
We conducted a cross-sectional, observational study to assess and compare the knowledge of medical students and residents in Lebanon and Saudi Arabia, regarding blood transfusion practices. Participating institutions were Alfaisal University (AU), College of Medicine located in Riyadh, Saudi Arabia, King Faisal Specialist Hospital (KFSH) and Research Centre located in Riyadh, Saudi Arabia, the Balamand University (BU), College of Medicine located in Beirut, Lebanon, and the Lebanese American University (LAU) Gilbert and Rose-Marie Chagoury School of Medicine, located in Byblos, Lebanon.
The study investigators developed a self-administered online knowledge-based survey. The survey was designed to cover different aspects of transfusion medicine that are accepted as relevant and important topics by the content experts. Therefore, the survey has a face validity as well as a content validity. It consisted of 26 questions: 4 about personal data and experience with transfusion, 6 about blood donation and donor selection, 2 about production and storage of blood components, 4 about the selection of appropriate blood components, 5 about the administration of blood components, and 5 about transfusion reactions and complications.
As many medical schools, including those participating in this study, accept 60% as the passing grade for knowledge-based examinations, this level was accepted as the desired level for this knowledge-based survey.
The survey was sent to clinical clerkship students at AU, the BU, and the LAU. The survey was also sent to residents of various departments (Internal Medicine, Pediatrics, Surgery, Obstetrics and Gynecology, Hematology/Oncology, and Orthopedics) at KFSH, the BU, and the LAU. All research subjects were informed of the aim and objectives of the research by a meeting and/or written information about the study. IRB approval was obtained before the study from relevant boards of participating universities.
The data were automatically entered into an electronic database and prepared for analysis. The data analysis involved two steps. The first used descriptive statistics by way of contingency tables. Next, specific relationships between categorical variables were examined using the Pearson's Chi-square test or Fisher's exact test, as appropriate. Data management and analysis were carried out using the Statistical Package for the Social Sciences (SPSS (IBM)), version 21 for windows. A significance level of P < 0.05 was used.
| Results | | |
One hundred and twenty-six students from Saudi Arabia and 84 from Lebanon participated in the survey. In addition to that, 31 residents from Saudi Arabia and 23 from Lebanon participated in the survey [Table 1]. All participants completed the survey.
There were clear differences between students and residents in questions regarding their experience in observing transfusions and transfusion reactions and ordering transfusions, with the residents being much more experienced than students as expected [Table 2].
There were no significant differences between the correct answer rates of students and residents. Similarly, there were no differences between the correct answer rates of students according to countries [Table 3]. The overall knowledge about transfusion practices was the same between students and residents and did not seem to improve with time and training.
The correct answer rates in the five categories are shown in [Table 4]. The percentages of correct answers were below the desired level of 60% in all categories.
| Discussion | | |
Rational use of blood is a major issue for public health, due to poor inventory, high cost, and concerns on patient safety.[1] Human blood donations remain the only reliable source of supply, and amid the COVID-19 pandemic and the series of lockdowns, ease of access has become a significant challenge.[1] Therefore, blood components should be appropriately used, and waste should be reduced to provide proper stock maintenance to meet the needs of patients who have true indications for a blood transfusion.[1] Many studies addressed the issue of inappropriate blood usage and strategies to correct this.[6] Therefore, knowledge about the proper use of blood components, recognition, and management of transfusion complications are essential in medical practice.
There are no studies addressing the level of knowledge and education on blood transfusion practices in medical schools and during residency in the Middle East and particularly in Lebanon and Saudi Arabia. In this study, the first one from Lebanon and Saudi Arabia addressing this important issue, there was no significant difference between students' and residents' level of knowledge. In other words, the knowledge of residents is not better than that of students. On the other hand, it is noteworthy that the correct responses (48% and 46%, for students and residents, respectively) are well below 60% for both groups. This reflects the need for more vigorous and well-structured education and training for both students and residents.
Similar results were found in a study carried out among 3009 final-year (6th year) medical students (interns) from 13 different medical schools in Turkey. Sixty-five percent of the students reported that transfusion medicine education was insufficient. Only 14% of the students felt competent in recognizing transfusion complications and applying first-line treatment. Fifty-two percent of the students felt uncomfortable initiating and monitoring transfusions, while 41% stated that they could manage under the supervision and 7% stated that they had sufficient practice. Regarding their theoretical knowledge, they were able to recognize 50% of the correct and 30% of the incorrect information in the test with 10 questions and 53 choices.[7]
A study in Iran among physicians addressing their knowledge of transfusion medicine has shown that on average, only 33% of the questions were answered correctly. The correct answers were 22%, 37%, and 40% about basic knowledge, the clinical aspect of transfusion medicine, and transfusion reactions, respectively.[8]
This lack of sufficient education in transfusion medicine is also a universal problem. Müller has conducted a survey about the status of transfusion medicine education and training across Europe and has reported that education in transfusion medicine training varies across countries and there are many deficiencies. While transfusion medicine is included in undergraduate curricula in 12 European countries, there are no subjects for transfusion medicine in five countries.[4] A forum survey was conducted with the contribution of 16 participants from 16 countries. It was seen that while transfusion medicine is included in the residency curriculum for certain departments, such as hematology and pathology, it is not included in others. Almost all participants have agreed that the knowledge of transfusion medicine should be enhanced and should be increased for both students and residents.
The participants from Sweden felt that there is a need for an increase in education regarding transfusion for residents in other fields of clinical medicine (e.g., hematology, internal medicine, and intensive care). It was concluded that education in transfusion medicine for students and residents should be enhanced because of its great importance in clinical medicine.[3],[4] In a study done by O'Brien et al., 41.4% of the final year's postgraduate residents stated that they had received no formal training in transfusion medicine during their graduate courses.[9]
Concerns about the level of knowledge of doctors regarding transfusion medicine are truly universal, and several studies have shown that knowledge of doctors falls short on basic hematology issues as well as transfusion medicine.[8],[9],[10],[11] Medical students should be the first target population because if they do not receive proper training in transfusion medicine, this knowledge gap is carried onto their practice as physicians. It appears that students in the last 2 years of medical school and the first 2 years of postgraduate training are the ideal targets for initial transfusion medicine training and education, which should be continued and carried out during their career.[2] A review has indicated that a more extensive education in transfusion medicine improves the knowledge of the trainees, as shown by tests before and after the training. In addition to this, learners agree that additional training in transfusion medicine is both helpful and desired.[2] Kaur et al. have found the overall pretraining assessment of fresh graduates for blood transfusion to be 51%, which has increased to 85.4% after training.[12]
A study performed in New York among physicians from various specialties showed an improvement in the knowledge about transfusion medicine even after a few hours of formal education about the topic.[11] A survey conducted in the United Kingdom assessed knowledge about transfusion medicine of resident physicians using questionnaires and noted that higher scores were achieved by physicians who received education about hematology during their graduate courses.[13] Rebel et al., in a study conducted in the United States, found that knowledge of anesthesiology residents related to transfusion medicine increased after they spent some time in a hematology service.[14]
A study by Panzer et al. in the form of getting expert views about transfusion medicine education in several countries, including Brazil, Iran, Australia, Sweden, Germany, India, Indonesia, Israel, Japan, and France, concluded that hematology education of students and residents in most countries is not homogeneous, as the curricula vary greatly between countries and between medical schools. They suggest that the main reason might be the lack of a national curriculum, except for Iran, where there is a national curriculum for transfusion medicine. The main conclusion of the forum was that transfusion medicine education should be intensified for students and residents.[3]
Haspel et al. have also shown that many residency programs offer less than 3 h of transfusion medicine education.[10] However, several studies have shown a correlation between increased transfusion medicine education and examination scores. Haspel also showed that residents who reported more than 2 h of transfusion medicine training during medical school rated their training as very or extremely helpful and did significantly better on the examination. This study also confirms the variability and relatively minimal amount of training in transfusion medicine in medical schools, regardless of country.[10]
A study that applied a questionnaire to evaluate the knowledge of medical residents on transfusion medicine in nine countries found significant associations between the scores and curriculum time in medical schools; those who received more than 2 h of training during their training had higher scores than those who did not.[10] As a result, they conclude that transfusion medicine is learned in practice without an adequate theoretical basis and real knowledge of the numerous risks related to transfusions.
Tinmouth et al. performed a systematic review of behavioral interventions, including education, and found that the interventions resulted in a relative reduction in the number of units (range, 9%–77%) and patients transfused (range, 17%–79%).[6]
Another study performed among clinicians also showed a general lack of knowledge of transfusion medicine across all specialties and training levels and indicates that additional education is needed.[11] It has been argued that knowledge of transfusion medicine correlated with improved decision making and the quality of care received by patients. These findings underscore the need for and the potential efficacy of educational interventions.[11]
Our study showed a lack of transfusion medicine knowledge among students as well as residents in two countries where the study was performed.
| Conclusion | | |
Medical students and residents are involved in ordering blood components, supervising patients receiving transfusions, and other aspects related to transfusion medicine. Knowledge related to transfusion reactions and risks is an important area in the practice of medicine for patient management in any specialty. Thus, education should be provided, not only for practicing physicians but also for all health-care workers. Several studies and surveys have proved that this is a universal issue that needs to be targeted. Knowledge in transfusion medicine across all specialties, students, and postgraduates can easily be improved with more time devoted to it in the curriculum. This study emphasizes the importance of improving trainee education for transfusion medicine.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Vasconcelos Vaena MM, Cotta-de-Almeida V, Alves LA. Transfusion medicine in medical education: An analysis of curricular grids in brazil and a review of the current literature. Rev Bras Hematol Hemoter 2016;38:252-6.  |
| 2. | Lin Y, Haspel RL. Transfusion medicine education for non-transfusion medicine physicians: A structured review. Vox Sang 2017;112:97-104. |
| 3. | Panzer S, Engelbrecht S, Cole-Sinclair MF, Wood EM, Wendel S, Biagini S, et al. Education in transfusion medicine for medical students and doctors. Vox Sang 2013;104:250-72. |
| 4. | Müller N. Overview of transfusion medicine in europe: Training and education. Blood Transfus 2005;3:248-52. |
| 5. | Ngo A, Masel D, Cahill C, Blumberg N, Refaai MA. Blood banking and transfusion medicine challenges during the COVID-19 pandemic. Clin Lab Med 2020;40:587-601. |
| 6. | Tinmouth A, MacDougall L, Fergusson D, Amin M, Graham ID, Hebert PC, et al. Reducing the amount of blood transfused: A systematic review of behavioral interventions to change physicians' transfusion practices. Arch Intern Med 2005;165:845-52. |
| 7. | Kupesiz FT, Ocak S, Koc BS, Evim MS, Tufekci O, Kintrup GT, et al. Evaluation of the knowledge of intern doctors on transfusion medicine in Turkey. Research Square. 2020. DOI: https://doi.org/10.21203/rs.2.22224/v1. |
| 8. | Gharehbaghian A, Javadzadeh Shahshahani H, Attar M, Rahbari Bonab M, Mehran M, Tabrizi Namini M. Assessment of physicians knowledge in transfusion medicine, Iran, 2007. Transfus Med 2009;19:132-8. |
| 9. | O'Brien KL, Champeaux AL, Sundell ZE, Short MW, Roth BJ. Transfusion medicine knowledge in Postgraduate Year 1 residents. Transfus 2010;50:1649-53. |
| 10. | Haspel RL, Lin Y, Mallick R, Tinmouth A, Cid J, Eichler H, et al. Internal medicine resident knowledge of transfusion medicine: Results from the best-test international education needs assessment. Transfus 2015;55:1355-61. |
| 11. | Arinsburg SA, Skerrett DL, Friedman MT, Cushing MM. A survey to assess transfusion medicine education needs for clinicians. Transfus Med 2012;22:44-9. |
| 12. | Kaur P, Kaur G, Kaur R, Sood T. Assessment of impact of training in improving knowledge of blood transfusion among clinicians. Transfus Med Hemother 2014;41:222-6. |
| 13. | Graham J, Grant-Casey J, Alston R, Baker P, Pendry K. Assessing transfusion competency in junior doctors: A retrospective cohort study. Transfus 2014;54:128-36. Available from: http://www.mmc.nhs.uk. [Last accessed on 2021 May 18]. |
| 14. | Rebel A, Hassan ZU, Boral L, Lin Y, Dilorenzo A, Schell RM. Initial results of a structured rotation in hematology and transfusion medicine for anesthesiology residents. J Clin Anesth 2011;23:469-74. |
Correspondence Address:
Sabri Kemahli,
Department of Pediatrics, College of Medicine, Alfaisal University, P O Box 50927, Riyadh 11533
Saudi Arabia
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/ajts.ajts_150_21
[Table 1], [Table 2], [Table 3], [Table 4] |
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