IT’S A SIGN OF THE TIMES that coordinating the infusion of monoclonal antibodies for covid patients—a therapy that’s always been outpatient only—is now, in Holland, Mich., at least, headed up by a nurse who co-manages the ED at the community hospital.
That’s the role that Marcy Achterhof, MSM, RN, has played since last November, when a monoclonal antibody received emergency use authorization (EUA) from the FDA to treat mild-to-moderate covid in patients at high risk of progressing to severe disease. Ms. Achterhof, along with an infection prevention nurse and pharmacist within Holland Hospital, helped craft a protocol now used throughout the surrounding community to ensure that covid patients who meet criteria for the treatment receive it.
They also set up what they call an antibody clinic within their own ED; hunt daily through covid lab results from the ED as well as from local primary care offices, urgent care clinics, drive-through testing sites and skilled nursing facilities, looking for positives; and push order forms to outpatient providers to get appropriate patients infused as fast as possible. “Time is of the essence with this therapy,” Ms. Achterhof points out. “Technically, we have 10 days from symptom onset to administer treatment. But our goal is to do so between 24 and 48 hours after getting a positive result.”
A change in protocols
When monoclonal antibodies first came online last fall to treat covid, it was clear that the traditional infusion protocols in place at Holland Hospital would need to be changed. Previously, monoclonal antibody infusions had been administered in the hospital’s ambulatory treatment unit—a unit full of immunocompromised patients and those on chemotherapy. Providers needed other arrangements immediately so such patients wouldn’t be at risk from those infected with covid.
“Time is of the essence with this therapy.”
~ Marcy Achterhof, MSM, RN
Holland Hospital
According to Ms. Achterhof, some hospitals have solved that dilemma by building brand new infusion centers for covid patients only. Holland Hospital instead decided to set aside four beds in a section of its ED every morning—that’s the antibody clinic—to infuse covid patients. The infusions are considered ambulatory treatment unit visits, not ED visits.
“Those beds already have IV start equipment, an IV pump and a vitals machine,” Ms. Achterhof points out, “as well as a nurse who’s running the clinic that morning.” Each infusion—and covid patients get only one—takes about a half hour to administer, with patients then monitored an additional hour. With four beds reserved between 7 a.m. and 11 a.m., Ms. Achterhof says the clinic can accommodate eight patients a day.
In lieu of the antibody clinic, outpatient clinicians and facilities—as well as the ED when it discharges covid patients—can order an infusion for patients with covid through home health, according to a protocol hammered out last fall. But as Ms. Achterhof explains, patients can run into barriers qualifying for home health care.
“They have to meet certain criteria if they’re not already a home health client, and they have to first have a face-to-face encounter,” she says. “It turns out that about 90% come through the clinic for the infusion, with 10% done by home health.” Another route: Patients admitted for other medical reasons such as a hip fracture who turn out to be covid positive can be infused on the hospital floors. That, Ms. Achterhof says, happens infrequently.
Communication and outreach
Coordinating antibody treatment for the community has turned out to be a challenge, due in part to rapid changes in the medications themselves.
The first FDA EUA, Ms. Achterhof recalls, was issued for bamlanivimab alone in November; in February, however, an EUA was issued for bamlanivimab with etesevimab. But the FDA paused the use of those two agents earlier this year because of concerns about their effectiveness against the delta variant. The agents now being used are casirivimab and imdevimab, which are administered together (REGEN-COV).
“Three different iterations of medications in less than a year is unheard of,” says Ms. Achterhof. “Processes and indications change, but medications typically don’t.” She and her workgroup at Holland Hospital rely on updates from the Michigan health and human services department.
“We’re a big enough hospital to do big things, but we’re small enough to be agile,” she points out. “We can make these kind of changes almost immediately.”
The hospital has also had its share of challenges when it comes to communication with—and outreach to—community providers to keep them up to date with changing evidence and protocols.
The local PHO (physician hospital organization) has long served as a liaison for information between the hospital and outpatient providers. During the pandemic, however, the PHO”s work has intensified and become more broad. While many outpatient providers—as well as the home health department—are employed by the hospital, the PHO is now reaching out to outpatient clinicians who aren’t hospital-affiliated, as well as to local communities, including migrant workers, that may not have clear access to health care resources.
Local providers know that the PHO puts out a newsletter every Friday, says Ms. Achterhof, which is “the one communication they need to pay attention to. That newsletter underscores what, in terms of evidence and protocols, has changed in treating covid,” including what has been overridden or discarded.
Making orders easy
With orders for antibody treatment still done via paper, Ms. Achterhof and other members of the hospital’s antibody work group review community lab results daily, then fax patient information and order forms for positive patients to outpatient providers and clinics. The outpatient providers have to only sign and fax them back to get patients scheduled for an infusion.
“We’ve been successful pushing those order forms on our end,” she points out. “We’re making it as easy as possible for the offices or clinics.”
Ms. Achterhof also finds out from local practice managers the best day and time when most of their providers and staff are eating lunch together. “I call it a “lunch and learn session,” ” she notes. “I don’t do a PowerPoint, and I don’t bring food. I just show up with a manila folder that has the most recent EUA criteria.” It’s an opportunity for those practices to put a face with her name and to ask questions about the treatment and the protocol.
Ms. Achterhof also makes sure that providers and clinics throughout the community have her cellphone number so they can call with any questions about which patients meet criteria for the therapy.
“It’s typically only a one-or two-minute conversation, or we find out a patient can’t come in in the morning, so we schedule an infusion for other times,” says Ms. Achterhof. “We’ve been told by our administration that this treatment is an absolute priority.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Published in the September/October issue of Today’s Hospitalist
