ABSTRACT
Background. Providing a safe discharge in patients appropriate for outpatient parenteral antimicrobial therapy (OPAT) became an important focus of the inpatient to outpatient transition during the pandemic. Hospital beds were needed for ill patients with COVID;transfers in and out of facilities and interfacility infection became issues for long-term care (LTCF) and short-term nursing facilities (SNFs) in the US during the pandemic. We examine the traditional barriers, including age, and outcomes of patients selected for OPAT initiation during the pandemic period. Methods. Washington DC VAMC (WDVAMC) is an urban medical center with 220 acute and LTC beds. At the start of the pandemic, a multidisciplinary OPAT program was initiated and led by ASP Nurse Practitioner (NP), supported by ASP Pharmacist and ASP/ID Physician. OPAT included care continued at home, SNF, LTC and hemodialysis locations;the OPAT program focus was on appropriate selection, post-discharge safety monitoring, outpatient follow-up at completion, tracking and outcome determination (30D, 90D readmissions). OPAT related readmissions related to drug or opat-indicated infections. Results. BetweenApril 2020-2022, 157 uniqueOPAT discharges (10.4OPAT/1,000 admissions 2020 and 4.8OPAT/1,000 admissions 2021);themajority were offeredOPAT at home (47%).Mean durationOPAT22+/-13days over that period;most frequent indication osteomyelitis and BSI. OPAT related readmissions were infrequent at 30D (7%) and 90D(1%).The meanage was 67+/-13y with 5%>90yrs, 21%>75yrs and 58%>65yrs. In the pandemic 92% completed OPAT;compared to younger group those >75y, rates of completion (93%vs 92%, P=NS) and mean duration of OPAT were similar however amodest increase in 90D OPAT-related readmission (1.2% vs 0%, P=0.04). The only two deaths prior to completion of OPAT occurred in those >75y. Conclusion. Transitions to OPAT are required for serious infections in hospitalized patients of all ages, however transitions to SNF and LTC were limited at times during the pandemic. We found OPAT can be delivered safely, regardless of age during a pandemic state with careful coordination between stakeholders and a systematic process to monitor outcomes and track patients, particularly for the elderly.
ABSTRACT
Background. In the setting of the global pandemic due to COVID-19, high-risk patients with mild to moderate disease were identified as a group who would benefit from COVID-19 monoclonal antibody (mAB) treatment to mitigate progression to severe disease or hospitalization. The U.S. Food and Drug Administration (FDA), under Emergency Use Authorizations (EUA) approved multiple COVID-19 mAB therapies with specific criteria for eligibility of candidates, documentation of discussion with patients, and reporting of all errors and serious adverse events. Methods. A cross discipline working group implemented a mAB clinic at complexity level 1a VA Medical Center in metropolitan Washington, D.C. through collaboration of personnel committed to patient care. The team successfully persuaded hospital leadership to provide space and leveraged technologies for rapid communication and dissemination of education. A stewardship driven medical center wide surveillance system rapidly identified outpatients for screening;primary care and ED providers were engaged through various electronic methods of education, including email, web-based team communication, intranet webpages and other electronic modalities. Within the EMR, an order panel was implemented to assure that the key requirements of the EUA were met and the provider was guided to the appropriate mAB, nursing, and PRN rescue medication orders. Results. Of over 17,000 COVID-PCR tests were performed at our medical center, 198 outpatients were screened and 16 received COVID-19 mAB infusions between January 2, 2021 to May 31, 2021. One patient experienced a reaction requiring the infusion to be stopped and supportive medications to be administered;there were no long-term sequalae reported as a result of this event. Conclusion. A multidisciplinary collaboration is well suited to implement innovative processes and policies for novel therapies in the middle of a pandemic. An agile workflow, regular communications between members of the workgroup, and commitment of institutional leadership helped facilitate the changes necessary to provide our patients the opportunity to receive potentially life-saving therapies.