Q&A with Robert A. DeSimone, MD
Director of Transfusion Medicine
New York-Presbyterian Hospital/Weill Cornell Medicine
Medical Lab Management: What trends have you seen regarding blood product utilization over the last 15 months?
Robert DeSimone: When the pandemic began, hospitals faced a mild shortage as blood drives ceased operating due to social distancing mandates and general concern for the spread of SARS-CoV-2. However, demand also decreased with the cancellation of most elective procedures and low blood utilization by COVID-19 inpatients. That said, hospitals experienced a substantial blood shortage approximately two months into the pandemic when many elective surgeries resumed. As demand quickly increased, the blood supply struggled to keep pace leading to a challenging situation at hospitals around the country.
As the country faced subsequent waves of the pandemic in the time since, additional, smaller shortages occurred unpredictably and with little or no notice. The current blood supply is tenuous as blood drives, which had been held commonly at schools, churches, hospitals, and places of work, remain scarce. As was true before the pandemic, the summer months in particular have been challenging to recruit donors, an issue that has only been exacerbated by the pandemic.
MLM: With time to reflect, what initial response actions proved most helpful?
DeSimone: There are two actions that have proved particularly helpful from the beginning of the pandemic:
Prospective auditing requires a great deal of effort and medical knowledge, and we were lucky at my institution to have pathology residents perform this critical service 24/7 during the first wave. Our clinicians enthusiastically partnered with us to reduce unnecessary transfusions, as they were aware of the severe blood shortage that was occurring across the nation. Upon review of red blood cell order requests in patients with a hemoglobin of >7 g/dL and after clinical consultations with ordering health care providers, we were able to reduce several transfusions and remain in compliance with current evidence-based guidelines.
MLM: What are the clinical factors associated with need for transfusion in COVID-19 patients?
DeSimone: We have found that patients with COVID-19 actually tend to have a low overall need for transfusion. During the first wave of the pandemic, only 3.3% of inpatients with COVID-19 at our institution required blood products. That said, patients indicating an array of severe disease markers, including intubation and ICU admission, as well as markers of coagulopathy, such as prolonged PT and aPTT, were associated with the need for blood. Not surprisingly, lower platelet and hemoglobin nadirs also were associated with transfusion and patients experiencing thrombosis required blood products at higher rates. It was helpful to track these clinical and laboratory markers in COVID-19 inpatients to optimize management of the blood bank inventory.
MLM: What is the role of randomized controlled trials in evaluating convalescent plasma efficacy and safety?
DeSimone: Throughout the pandemic, there has been substantial pressure to administer COVID-19 convalescent plasma (CCP) to patients with COVID-19 via the FDA’s expanded access program and eventually via their emergency use authorization. However, the safety and efficacy of CCP were unknown early in the pandemic and plasma is well known to have adverse effects in general. Our institution participated in a clinical trial of convalescent plasma in patients with severe influenza before the pandemic that showed no significant effect of the plasma treatment on respiratory status. With this in mind, we opted to join an international, randomized controlled trial to study the use of CCP in a more rigorous fashion. The patient population in our trial—those with early COVID-19—were most likely to see the greatest benefit from CCP based on our knowledge of its efficacy in similar viral respiratory illnesses.
MLM: What did your transfusion service do to prepare for potential blood product and staffing shortages?
DeSimone: In addition to the aforementioned announcements, our hospital transfusion services met on a regular basis to discuss mitigation strategies of all potential blood product and staffing shortages in our laboratories. We developed a planned, pre-set response to address these challenges as the situation evolved (see FIGURE 1)1. Although we remained in the Green zone for the entire first wave, it was helpful to develop a framework and think through the potential challenges before they occurred.
MLM: What have been the effects of decreased blood supply on the patient blood management program?
DeSimone: Although we had a strong patient blood management (PBM) program before the pandemic, the decrease in the blood supply served as an opportunity to remind clinicians of important PBM principles and guidelines. As a result, we saw a significant decrease in red blood cell utilization in patients with a hemoglobin >7 g/dL, which is in agreement with our guidelines.
MLM: A common research question asks whether COVID-19 convalescent plasma (CCP) transfused into patients mitigates the risk of intubation or death. What have your studies found?
DeSimone: The results of the very large international trial we participated in, CONCOR-1, will be published imminently. The trial stopped enrollment early in January 2021 after meeting the pre-defined threshold for futility, meaning the study was unlikely to demonstrate a benefit of convalescent plasma even with the enrollment of more patients.
MLM: Since publishing your paper on this topic in late 2020,2 what feedback have you received from colleagues and peers in the clinical community?
DeSimone: The transfusion medicine community faces shared challenges in maintaining a robust blood supply to meet our patients’ needs. The community has really come together nicely to communicate these challenges and develop tools, such as CCP utilization guidelines, to better manage the crisis. I am grateful for our colleagues in transfusion medicine who have reached out after publication of our work to share their own experiences and offer how our findings influenced their practice.
Robert A. DeSimone, MD, is director of transfusion medicine at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and an assistant professor of pathology and laboratory medicine at Weill Cornell Medicine.