suggest that not everyone is doing it correctly, but we do not yet know enough. More research is needed in this area.

Toby Simon: Studies with humans are difficult to do and are usually open to methodological criticisms. They do not fare well in the peer review process, and it has been very difficult to get them funded.

Elaine Eyster: Many of the transfusions in this country are initiated by house officers, at least in teaching hospitals. Often, the attending physician does not find out about it until after the patient has received the transfusion. Perhaps there should be efforts to work with medical schools and training program directors to develop algorithms for given situations.

Thomas Zuck: Many medical schools face the problem of competition, particularly in the senior year—for educational time. Transfusion medicine must compete with everything else; it is extremely difficult to get the hours.

Toby Simon: The Transfusion Medicine Academic Awards was an NIH program supported by the AABB, CCBC, CAP and others that was carried out for a number of years. The literature describes the practice of the "just-in-time" consult, in which a physician expert in transfusion medicine is involved immediately on receiving an order. This could be very effective with house officers in particular. The College of American Pathologists does support the effort through its work in the Joint Commission, by their Requirement for Transfusion Committees and Review. But all of these have fallen short of what we want to achieve, however.

Arthur Caplan: In many hospitals the transfusion committees are now called "utilization and review committees." That is, a heavy emphasis is placed on guidelines for transfusion within hospitals. Active program utilization review is short of the ideal, but it does exist and is an ongoing activity. It may now be at the point at which most of the business of those committees is the review of transfusions given outside the guidelines. It is not a total vacuum in terms of utilization review and efforts to teach algorithms or standards.

Elaine Eyster: We must take the next steps. Transfusion information has not been well disseminated. Most teaching hospitals are not practicing those steps, and are not likely to find it possible to have a knowledgeable advisor available at the time of every transfusion.



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