A research letter today in JAMA Network Open describes how nurses in Michigan may have reduced emergency department visits and hospitalizations of high-risk COVID-19 patients by coordinating at-home administration of neutralizing monoclonal antibodies (MABs) during the spring 2021 surge.
From February to May 2021, three nurses at St. Joseph Mercy Health System in Ann Arbor reviewed new positive COVID-19 test results and provider referrals from the system's hospitals to determine if patients were eligible for MAB administration under the Food and Drug Administration emergency use authorization (EUA).
After the EUA, health systems struggled to implement MAB infusions because of difficulty with patient identification and enrollment, infection-control concerns, and finding enough space, resources, and workers amid the winter surge. Implementation of MAB administration has varied, the authors said, and tends to be facility-specific, often using outpatient infusion centers or emergency departments (EDs).
In spring 2021, the Michigan Department of Health and Human Services (HHS) reported that up to 30% of COVID-19 patients may qualify for MAB and set a goal of infusing at least half of them.
The nurses worked with community-integrated paramedics to schedule home infusions of MABs provided by the Michigan HHS at no cost, and the health system provided infusion supplies. A medical director provided expertise and clinical support to the paramedics, who worked under a newly developed standardized paramedicine protocol.
5.6% hospitalized after worsening symptoms
During a 14-day follow-up, 8 of 144 infused patients (5.6%) were hospitalized for an average of 3.3 days after their symptoms worsened. One patient (0.7%) was hospitalized after a hypersensitivity reaction, and 2 (1.4%) visited an ED for the same indication. None of the patients required intubation, and all were released from the hospital.
The authors didn't provide estimates of how many hospital visits the program may have averted.
Administration costs included nurse time ($1,250 a week at roughly $50 an hour for 25 hours for all three). The Centers for Medicare & Medicaid Services reimbursed the health system $310 per infusion initially and then $750 starting in early May. In turn, the health system reimbursed the paramedics for MAB administration to patients not covered by Medicare or other health insurance at the initial Medicare reimbursement rate.
Twenty patients (13.9%) were part of households in which several members were given infusions. Average patient age was 60.1 years, 57.6% were women, and 86.8% were White.
The authors said that the infusions were critical in preventing high-risk COVID-19 patients, regardless of health insurance status, from needing to visit an ED or be hospitalized during a time when hospitals were overwhelmed with cases.
"At a time when physical and health care worker resources were significantly strained, our real-world approach leveraged the ability of nurses to identify, triage, and coordinate home MAB infusions while successfully preventing high risk patients from progression to severe disease and hospitalization," the authors wrote.
The National Institutes of Health and the Infectious Diseases Society of America recommend MABs for the treatment of nonhospitalized COVID-19 patients with mild or moderate illness at high risk for poor outcomes, the authors noted. The EUA covers bamlanivimab and etesevimab, manufactured by Eli Lilly, and the Regeneron combination of casirivimab and imdevimab.
