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ORIGINAL ARTICLE
J Edu Health Promot 2020,  9:173

Digital resources for transfusion education


1 Department of Biotechnology, Haematology and Haemotherapy Unit, Poniente Hospital Public Health Agency, El Ejido, Almeria, Spain
2 Department of Integrated Training, Poniente Hospital Public Health Agency, El Ejido, Almeria, Spain
3 Information Technology Department, Poniente Hospital Public Health Agency, El Ejido, Almeria, Spain
4 Department of Biotechnology, Poniente Hospital Public Health Agency, El Ejido, Almeria, Spain

Date of Submission24-Jan-2020
Date of Acceptance10-Mar-2020
Date of Web Publication28-Jul-2020

Correspondence Address:
Dr. Maria-Angustias Molina-Arrebola
Department of Biotechnology, Haematology and Haemotherapy Unit, Poniente Hospital Public Health Agency, Address: Carretera De Almerimar S/N, 04700, El Ejido, Almeria
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jehp.jehp_81_20

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  Abstract 


INTRODUCTION: Regular training in the blood transfusion process is crucial for transfusion safety. Hospital transfusion committees have an obligation to provide this education to hospital employees through training activities. E-learning is positioning itself as a valid alternative to physical-presence courses.
MATERIALS AND METHODS: We describe a training course on blood transfusion to members of our hospital who are involved in the transfusion process, including technicians, nurses, and doctors. The course uses Moodle as the e-learning platform; it is evaluated using a satisfaction survey along with a knowledge-transfer and impact survey a year after taking the course.
RESULTS: From 2015 to 2018, seven editions of the online transfusion course were developed. Six hundred and eighty students enrolled; of these, 124 did not take the final examination (18.2%); 60 never began the course (8.8%). Of the 556 students who completed the course, 546 passed (98.2%). The average score from the initial self-assessment was 7.3 while the average score from the final self-assessment was 9.2; the mean improvement was 1.9 (out of 10). The level of general course satisfaction was 9.27 (an average out of 10). More than 90% of the students stated that they were able to apply the acquired knowledge in the workplace after a year.
CONCLUSIONS: E-learning has demonstrated itself as an affordable solution that could help in the training of all staff involved in the transfusion process at our hospital, with the advantage that it includes general knowledge and particular skills in local transfusion medical practice.

Keywords: Blood safety, blood transfusion, e-learning, Moodle, patient blood management


How to cite this article:
Molina-Arrebola MA, Fernández-Guerrero E, Aguirre-Ortega FJ, Avivar-Oyonarte C. Digital resources for transfusion education. J Edu Health Promot 2020;9:173

How to cite this URL:
Molina-Arrebola MA, Fernández-Guerrero E, Aguirre-Ortega FJ, Avivar-Oyonarte C. Digital resources for transfusion education. J Edu Health Promot [serial online] 2020 [cited 2020 Aug 11];9:173. Available from: http://www.jehp.net/text.asp?2020/9/1/173/290955




  Introduction Top


The 2017 annual serious hazards of transfusion report stated in its initial keynote message “do not assume, verify: At each step in the transfusion process, do not assume that no errors have been made in previous steps; verify each step, particularly patient identification.”[1] There is a general consensus that regular training of all staff involved in the blood transfusion process (for the processes they participate in) is vital for transfusion safety. Transfusion committees advocate a risk-assessed approach, tailoring training to staff groups while taking into account factors such as individual practitioner's self-assessment regarding their own competency and transfusion-associated error rates.

Competency assessment was introduced to improve transfusion safety, calling on all staff who are clinically involved in the blood transfusion process to undertake an assessment of their own performance. The recommendation can be applied to practical transfusion skills such as sample labeling, collection, and the administration of blood components.[2] Training must be provided on each procedure for which employees are responsible, and the quality oversight personnel should assist in the development, review and approval of the training programs, including the retraining criteria.[3] In some countries, the role of transfusion practitioner has been implemented to improve transfusion processes focused on patient and staff education.[4] Globally, transfusion has been identified as an overused intervention by the choosing wisely campaign[5] and education initiatives are needed to determine the specific deficits and validated approaches for improving the current state of transfusion medicine.[6] One of the most important recommendations for patient blood management (PBM) implementation is that “Education should be provided to all clinicians involved in the decision to transfuse blood components in order to enhance their awareness of good PBM, including the avoidance of blood (transfusion) wherever possible.”[7]

Medical education is improving rapidly, both in complexity and advancement opportunities. Nowadays, active forms of continuing medical education (CME) are considered more effective than passive forms while internet-based CMEs, such as webinars or online modules, are successful at improving clinicians' performance.[8] Indeed, a meta-analysis of online learning in the health professions found little difference between the effectiveness of online and face-to-face formats.[6]

Our hospital, which was founded in 1996, is a 289-bed tertiary care hospital situated in southern Spain, which provides care for a local population of 273,719 people. Most of its transfusional activity focuses on medical areas, specialties such as internal medicine, intensive care, and accident and emergency; and in surgical areas, mainly general surgery, urology, traumatology, gynecology, and anesthesia. In 2018, 3342 units of blood products were transfused, 3149 units of erythrocytes, 139 units of fresh frozen plasma, and 54 platelet pools. Our erythrocytes transfusion rate is quite low (11.5 / 1000 population) since there is no clinical hematology or oncology units and because there is a hospital-wide blood saving awareness campaign with restrictive policies and the regular use of transfusion alternatives.

Our transfusion committee was created in 1999, and since its inception, one of its primary objectives has been to develop educational programs that promote the optimal use of blood components. Up until a few years ago, training courses were carried out where people attended in person. We have now developed an e-learning refresher course to take advantage of the new technologies, offering participants the timetable of their choosing so as to be compatible with their work and family life. In this course, we update and develop current hospital treatment guidelines, but in a dynamic way with the intention of making it attractive and practical.[9] The educational objective of this training activity can be summarized as the transmission of new practical concepts in blood therapy, crucial concepts, and skills to all the current medical, technical, and support staff working in medical fields related to the transfusion of blood derivatives, all focused on providing the patient with the greatest possible benefits in terms of therapeutic options and safety.

The aim of this study is summarize the results obtained after seven editions of our e-learning refresher course.


  Materials and Methods Top


This is a retrospective, observational study that analyzes the results of effectiveness and satisfaction among students and tutors after completing the course.

To develop this training activity, we used the Moodle digital platform,[10] a resource accessed from the teleformation interface on our hospital's website. The course became operational after learning and training period for those in the hematology department in charge of its coordination.

It is important to emphasize that the training activity design was structured according to the accreditation requirements of the Junta de Andalucía's Health Quality Assurance Agency. In accordance with the accreditation compliance criteria, the online course duration was set at 35 h over a 45-day period, with a maximum of 5-h online teaching/week. The course was divided into 7 thematic units [Table 1] with an approximate time/unit of 5 h. Up to two tutors were tasked with teaching each unit. The tutors were hematologists belonging to the hospital's transfusion committee, along with an anesthesiologist, who collaborated on the topic of autologous blood use.
Table 1: Education objectives of the e-learning course

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The student accessed the online training activity through the teleformation portal of the hospital's main website (www.ephpo.es, https://www.juntadeandalucia.es/ep-hospitalponientealmeria/Moodle) using their intra-hospital employee log-in details.

The training activities were divided into four main sections:

  • The introduction – this included the course's teaching guide, a glossary of common terminology, a question-and-answer forum, news related to the course's development, a course chat room and an initial self-assessment which was compulsory but not scored (so as to provide student guidance and to inform the faculty of the trainee's knowledge-based prior to training)
  • The teaching units – a total of 7 units developed in SCORM format using the EXE e-learning program.[11] The SCORM format has an intuitive and user-friendly design that allows readers to acquire knowledge in a dynamic and enjoyable way; this provides hyperlinks to official pages related to transfusion, interactive games, critical-thinking questions and examples of real situations, academic papers converted to PDF format, as well as the bibliography recommended for each unit
  • The course's general bibliography – with hyperlinks to the hospital's official treatment guide, official documents, regulations and access to official websites, etc.,
  • The final self-assessment-including the end-of-course training activity self-assessment, which is obligatory and scored; thus allowing us to assess each student's achievement. There is also a voluntary and anonymous course satisfaction survey, which provides very interesting and valuable feedback.


Both the initial self-assessment and the final self-assessment were composed of 10 questions randomly chosen from a bank of 20. To be awarded the diploma, students had to complete the initial, indicative self-assessment and the final, compulsory self-assessment; the latter required a 70% score rate, with a maximum of 2 attempts to pass. The questions are chosen by the hematologists and covered the knowledge or skills related to blood transfusion considered essential in our practice. A score rate of 70% is set (rather than a higher one) because the course is directed at doctors, nurses, and technicians so we do not demand a very high level of knowledge to pass the examination.

The examination score difference (the posttest score minus the pretest score) was calculated for all the trainees. As an example, we carried out a statistical analysis on trainees from the 5th group who had taken both tests to get a representation of the knowledge gain achieved from the training. The score difference was the outcome variable; a P < 0.05 was used to denote statistical significance (a paired t-test analysis, Excel, MS Office 2007).

Throughout the course, the organizers monitored the activity of each student in terms of subject reading, course progress, and self-assessment results.

Satisfaction surveys

The satisfaction survey was a general survey, voluntary and anonymous, validated by the Hospital Training Unit. It included general questions divided into scored questions (ranging from 1 to 4, from lowest to highest) and open-response questions.

Transfer and impact

Considered in terms of training transfer, and the effective and regular utilization of knowledge, expertise, skills, and attitudes learned as a result of a training activity, we were interested in determining how our health professionals had been influenced by the training they received. The main objective was to evaluate the real impact of this training activity on the student, both over time (short, medium, and long term) and in its scope, especially regarding the application of acquired learning.

The questionnaires were created using the Google Forms application, which is easy and intuitive, both for designing the forms and answering the questions (in a voluntary and anonymous fashion). Google Forms provides the functionality of generating graphics and data, which can be downloaded in excel for subsequent in-depth analysis. A year after completing the course, the organizers E-mailed the form link to the students and another similar survey to the tutors.


  Results Top


From 2015 to 2018, seven editions of the online blood transfusion refresher course were developed. Six hundred and eighty students enrolled; of these, 124 did not take the final exam (18.2%), 60 of whom never entered the course (8.8%). Of the 556 students who completed the course, 546 passed (98.2%) while only 10 students failed it [Table 2]. The average score from the initial self-assessment was 7.3 while the average score from the final self-assessment was 9.2 for the editions overall; the average improvement was 1.9 (out of 10). As an example, in the 5th group (n = 69), the median score from the initial test was 7 (with a standard deviation [SD] of 1.7) while the median score of the final examination was 9.1 (SD 0.8; P < 0.0001) [Figure 1].
Table 2: Summary of students enrolled on the online blood transfusion refresher course

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Figure 1: Example of scores in the 5th group: Initial and final self-assessment

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As for the course satisfaction surveys, 316 were received with an average level of overall satisfaction of 3.71 out of 4; translating to 9.27 out of 10. For survey details of overall student satisfaction regarding the different aspects of the course, as shown in [Table 3] and [Table 4].
Table 3: Satisfaction surveys received: Sex and average age of respondents

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Table 4: Overall levels of student satisfaction regarding the different aspects of the course

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The questions asking students for their opinions (which were not quantifiable) provided responses regarding the degree to which their course expectations had been met. They expressed great appreciation of both the course contents and the teachers, and stated that they had broadened the useful knowledge applicable in their daily professional practice, thus fully meeting their expectations. No negative opinions were expressed concerning the teleformation course format or its content.

As for the course's knowledge transfer and impact, the data gathered from the anonymous voluntary survey conducted a year after the course ended allowed us to collate the student surveys for the first 5 editions. The total number of surveys received was 131, and an average of 91.1% of students considered that they had been able to apply “a lot” or “some” of acquired knowledge in the workplace [Table 5].
Table 5: The course's knowledge transfer and impact: Assessment of the effects and usefulness of the training received according to the students

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For the open question, where students could add any opinions or suggestions, some examples included: “All the hospital staff should do this course from time-to-time in order to acquire or refresh their knowledge of blood transfusion;” “My suggestion is that all these courses should be continuously available, especially online, because this makes it more likely that they will be taken;” “There should be more courses of this nature applied daily at work; we improve as professionals, improve our response time and avoid forgetting things over the years;” “This type of refresher course should be given at least once a year.”

The total number of surveys received from the tutors was 12. An average of 95.8% of tutors considered that the students had been able to apply “a lot” os “some” of acquired knowledge in the workplace [Table 6].
Table 6: The course's knowledge transfer and impact: Assessment of the effects and usefulness of the training received according to the teachers

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Finally, it should be noted that the course was recognized by the Andalusian Health Quality Agency, which awarded 5.08 credits to the first 4 editions and 6.96 credits to the 3 latter editions.


  Discussion Top


In accordance with the literature, there are few studies looking at all the health-care workers participating in transfusion procedures, including nurses and paramedical staff such as laboratory technicians;[12],[13] however, the transfusion process as a whole, from the initial correct indication up to the transfusion procedure, it is not carried out and supervised by medical staff alone – for this reason, we believe that everyone in the process should have sufficient knowledge to guarantee patient security, and that is why our training program was designed for all the staff involved.

The results from the BEST-TEST international education needs assessment concluded that, internationally, internal medicine residents have poor transfusion medicine knowledge and would welcome additional training;[14] likewise, the transfusion camp project evaluation of a transfusion education program for multispecialty postgraduate trainees showed that transfusion medicine knowledge is deficient at this level, and that education programs are needed.[15]

The main aim of our training program is to refresh the transfusional procedures of personnel working in the hospital during the course period; this was a registration acceptance requirement since the course is designed to offer continuous training that can be developed in the professional environment. Considering that the course was taken by staff who are already familiar with the transfusion process, the initial self-assessment scores demonstrated an acceptable knowledge of the procedures (with an average score of 7.3), and the final self-assessment scores (an average of 9.2), confirmed the high course's effectiveness compared with other evaluations.[16]

The traditional distance learning approach based on student self-access using textbooks, where minimal contact with the teaching staff takes place, is giving way to new training models. E-learning platforms and distance-communication spaces are being developed for training purposes, using information, communication technologies, and internet. For our training activity, we decided on Moodle, an “all-in-one” platform that offers the possibility of making courses 100% online, with the integration of topics in SCORM format and configurable self-assessments. It is web-based, so you can access it from anywhere, on any device and using different browsers. After a PubMed search, SCORM was scarcely used in the medical literature and no results were found in relation to transfusion.

The surveys responses have been overwhelmingly positive, pointing out the advantage of online learning not being subject to a fixed or compulsory schedule. On the other hand, our training unit considers this course to be one of the most highly valued and it has also been recognized by the Andalusian Health Quality Agency, attaining a high number of credits, despite it being online only.

Some countries have national online transfusion education programs (Bloodsafe https://bloodsafelearning.org.au/and LearnBloodTransfusion https://www.learnbloodtransfusion.org.uk/). We think that, in addition to these big national e-learning programs, which require important infrastructure and financing, there is room for much simpler and more affordable solutions that can offer training related to the staff involved. As Solh described in the knowledge translation series,[17] knowledge alone is insufficient in ensuring that clinicians and the health system act on that knowledge; methods are required that bridge the knowledge-to-action gap.

General knowledge is available in the national guidelines but each hospital should adapt them to the local practice and its own peculiarities. Consequently, one of the objectives of the transfusion committee should be to create local guidelines, disseminate them, and implement educational interventions to spread this knowledge to the target.[18],[19]

Considering the training transfer, the effective and regular utilization of knowledge, expertise, skills and attitudes learned as a result of a training activity,[20] we were interested in determining how our health professionals had been influenced by the training they received, and more than 90% considered that they were still able to apply the knowledge acquired in the workplace even after a year.

In summary, scientific literature demonstrates that knowledge of transfusion medicine is deficient among health professionals fresh out of medical school. Although our study has the limitations to develop in a relatively small hospital, and further studies are needed on education resources, we believe that this kind of courses with the advantages of online learning focused on the update of concepts and their applicability in the daily practice might be very useful. In terms of future research, the aim is to offer this course to professionals who have no on-the-job experience and would thus be suitable receivers for this kind of education resources.


  Conclusions Top


We have designed and developed an e-learning transfusion refresher course to take advantage of new technologies. It is based on the SCORM format and uses Moodle as the teleformation platform. Its main objective is to update and develop the current hospital treatment guidelines in a dynamic way. Our intention was to make it attractive and practical, and to include the crucial concepts and skills required by all of the staff involved in the transfusion process, be they doctors, nurses, or technicians. The level of satisfaction regarding the course's knowledge and impact has been very high, as expressed both by the teachers and the students. This gives us great encouragement to continue, expand and disseminate this type of online training as a new and effective learning tool; a learning approach that, up to now, has scarcely been reported on in the scientific literature.

Acknowledgment

We would like to thank Mr. Simon Turner for his help in revising the text.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bolton-Maggs P, Poles D. Serious Hazards of Transfusion (SHOT) Steering Group; 2017. p. 140. Available from: http://www.shotuk.org. [Last accessed on 2018 Aug 02].  Back to cited text no. 1
    
2.
Robinson S, Harris A, Atkinson S, Atterbury C, Bolton-Maggs P, Elliott C, et al. The administration of blood components: A British Society for Haematology Guideline. Transfus Med 2018;28:3-21.  Back to cited text no. 2
    
3.
Graham JE, Narayan S, Pendry K. Improving transfusion education for junior doctors; exploring UK experiences. Transfus Med 2017;27:96-104.  Back to cited text no. 3
    
4.
Miller K, Akers C, Davis AK, Wood E, Hennessy C, Bielby L. The evolving role of the transfusion practitioner. Transfus Med Rev 2015;29:138-44.  Back to cited text no. 4
    
5.
Choosing Wisely Lists-Transfusion; 2019. Available from: https://www.choosingwisely.org/?s=transfusion. [Last accessed on 2018 Jul 23].  Back to cited text no. 5
    
6.
Lin Y, Haspel RL. Transfusion medicine education for non-transfusion medicine physicians: A structured review. Vox Sang 2017;112:97-104.  Back to cited text no. 6
    
7.
Goodnough LT. Patient blood management. Anesthesiol 2012;116:1367-76.  Back to cited text no. 7
    
8.
Herbert C, Velan GM, Pryor WM, Kumar RK. A model for the use of blended learning in large group teaching sessions. BMC Med Educ 2017;17:197.  Back to cited text no. 8
    
9.
Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Internet-based learning in the health professions: A meta-analysis. JAMA 2008;300:1181-96.  Back to cited text no. 9
    
10.
Moodle. Available from: http://www.moodle.org. [Last accessed on 2018 Oct 29].  Back to cited text no. 10
    
11.
Exe-Learning Program. Available from: http://www.exelearning.net.[Last accessed on 2018 Oct 18].  Back to cited text no. 11
    
12.
Encan B, Akin S. Knowledge of blood transfusion among nurses. J Contin Educ Nurs 2019;50:176-82.  Back to cited text no. 12
    
13.
Rudrappan RB. Evaluating the knowledge and practices of nurses and paramedics in blood transfusion services - A survey in the states of Tamil Nadu and Pondicherry, India. J Educ Health Promot 2019;8:48.  Back to cited text no. 13
    
14.
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. Transfusion 2015;55:1355-61.  Back to cited text no. 14
    
15.
Lin Y, Cserti-Gazdewich C, Callum J, University of Toronto Transfusion Camp Organizing Committee. Evaluation of “transfusion camp,” a postgraduate transfusion medicine education program using the BEST-TEST knowledge assessment tool. Transfusion 2015;55:2049-51.  Back to cited text no. 15
    
16.
Yan MT, Arsenault V, Pendergrast J. Evaluation of immunohematology knowledge in hematology trainees. Transfusion 2019;59:2685-90.  Back to cited text no. 16
    
17.
Solh Z, Brouwers M, Florez ID. Knowledge translation in transfusion medicine. Part 1: The basics and the frameworks. Transfusion 2018;58:629-32.  Back to cited text no. 17
    
18.
Florez ID, Brouwers M, Solh Z. Knowledge translation in transfusion medicine. Part 2: Selecting the knowledge and identifying the barriers. Transfusion 2018;58:1097-9.  Back to cited text no. 18
    
19.
Solh Z, Brouwers M, Florez ID. Knowledge translation in transfusion medicine. Part 3: Interventions and tools. Transfusion 2018;58:1835-7.  Back to cited text no. 19
    
20.
Florez ID, Brouwers M, Solh Z. Knowledge translation in transfusion medicine. Part 4: Measurement and sustainability of knowledge use. Transfusion 2018;58:2104-7.  Back to cited text no. 20
    


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