(With inputs from Dr Monica Vasudeva)

801: Monoclonal Antibodies

The use of mAbs directed against infectious pathogens is an area of investigation. The mechanism is not completely understood. Potential uses include prevention or treatment of specific infections.

Most mAbs target proteins on the surface of a virus and neutralize the virus from entering cells. Palivizumab is an antibody against the respiratory syncytial virus (RSV) fusion (F) glycoprotein. It inhibits viral entry into host cells. The therapy got US Food and Drug Administration (FDA) approval for the prevention of RSV infection.

Other investigational preventive antiviral mAbs include those that target the conserved hemagglutinin A stem of Haemophilus influenzae. This therapy may help in cases in which vaccination offers ineffective humoral immunity.

Investigational mAbs against HIV can improve immunity during active infection, with promising results in animal models using broadly neutralizing antibodies

Some mAbs against bacteria can function both prophylactically and therapeutically, for instance, by targeting the protective antigen domain of Bacillus anthracis or one of the Clostridioides [formerly Clostridium] difficile toxins).

A 2018 editorial stated that mAbs directed against pathogens are unlikely to be used routinely owing to their high cost and requirement for parenteral administration; however, they may be especially useful for certain emerging infectious diseases.

Treatment of active disease and/or targeted prophylaxis might be important in individuals who have not been vaccinated against a pathogen but require immediate protection (those infected with Ebola virus, pregnant women residing in Zika virus-endemic areas and COVID-19). [Uptodate]

802:  Can COVID-19 be treated in OPD

OPD management is appropriate for most patients with suspected or confirmed COVID-19. Follow a coordinated care management program that includes initial risk stratification, clinician telehealth visits (telephone call or video platform-based), a dedicated outpatient respiratory clinic, and a close relationship with a local emergency department (ED).

Patients residing in regions with widespread community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and having compatible symptoms are generally managed presumptively as having COVID-19, even if they have not been tested or have an initial negative test result.

On initial evaluation, assess risk factors for severe disease, dyspnea severity and duration, as well as oxygenation status of those with dyspnea, overall level of acuity, and patient’s home setting to ascertain who warrants an in-person evaluation at an outpatient clinic or in the ED. [Uptodate]

803:  Refer to hospital

Patients with one or more of the following features should be referred to the ED for further management:

Severe dyspnea (dyspnea at rest, and interfering with the ability to speak in complete sentences)

Oxygen saturation on room air of ≤90%, irrespective of severity of dyspnea

Concerning alterations in mentation (confusion, change in behavior, difficulty in rousing) or other signs and symptoms of hypoperfusion or hypoxia, such as falls, hypotension, cyanosis, anuria, chest pain suggestive of acute coronary syndrome.

804: Refer to OPD CLINIC

• Mild dyspnea with an oxygen saturation on room air of 91-94 percent
• Mild dyspnea in a patient at high risk for severe disease
• Moderate dyspnea
• Symptoms concerning enough to warrant in-person evaluation (eg, mild orthostasis) but not severe enough to require ED referral

805: Stay at home

Other patients can generally remain at home for management without in-person evaluation if they are able to report worsened symptoms and can self-isolate for the duration of illness. The need for such patients requiring telehealth follow-up depends on their risk for severe disease and the extent of dyspnea.

806: Differential diagnosis

Symptoms of COVID-19 can overlap with those of several common conditions. It is, therefore, important to consider other possible etiologies of symptoms including other respiratory infections, congestive heart failure, asthma or chronic obstructive pulmonary disease (COPD) exacerbations, and even anxiety. Conditions that can be treated remotely will be treated without an in-person evaluation but with scheduled daily follow-up telehealth visits.

807:  Surgical practice opened in US

TO:         ASC Physicians, APC’s and Team Members (cc ASMMC Leadership Team)

FROM:  Rommel Bote, MD, CMO

Douglas A. Fehrman, MD, ASC President

Good Morning Team  -

We have received approval for starting all surgical elective surgeries on a soft opening starting May 11, 2020.  As of 05/05/20, please see the attached guidelines and required testing. We are a full go for all surgical specialties May 18, 2020.

Steps to consider:

Surgical providers will have to run a list with their nursing staff and triage patients who have been canceled, and will need to determine what patients meet the criteria to get patients scheduled for surgery

Pre-ops, H&P’s, MRSA swabbing and COVID-19 testing (within the 48-72 window) will need to be reviewed and scheduled if outside of recommendation

1. Please see testing guidelines if less or greater than 24 hours pending if urgent case or elective

Surgical provider has to order the COVID-19 test, clinic team (ordering physician’s office) will contact patient with results only (both positive and negative)

PSE team will contact patient to schedule COVID19 testing 4 days prior to surgery, will review test results once received and if positive will contact surgical office to determine if surgery will be canceled per algorithm attached

A new case request will need to be submitted if the prior authorization has expired

May 12th will be the opening of the drive-thru testing at the clinic, until then all COVID-19 testing will be conducted at the ED

We are hoping to schedule the patients who are within the allotted timeframes, authorizations are on file, no cardiac clearing is needed and can be placed on the surgery list to be scheduled who have been placed on the cancellation list prior to new case requests.

Surgeons - please ensure you work closely with your nursing team on completing the surgical prioritization (SWAPS process tool) which should have been communicated from your service line leader for instructions on how to complete to prioritize the urgency and approval for the procedure based on the scoring. Please let your clinic manager know if you have not received it.

We are currently working with the primary care team to determine the best workflow to accommodate the influx of pre-op appointment requests that will be submitted, so please note with the social distancing guidelines there will be some delay in getting patients in right away for their appointment.

Please include your clinic manager and supervisor for patient list so we can keep track of procedure counts.

Check the COVID weblink daily as guidelines and reactivation guidelines can change daily.

https://www.advocatehealth.com/covid-19-info/

COVID19 Pre-Surgical testing tip sheet for EPIC:

https://www.advocatehealth.com/covid-19-info/_assets/documents/testing/covid-19-pre-surgical-testing-tip-sheet-epic-hospitals.pdf

Essential Surgery and Procedure Criteria by Surgical Specialty:

https://www.advocatehealth.com/covid-19-info/_assets/documents/emergency-department-hospital/aah-covid-urgent-surgery-guidelines-vi-04-23.pdf

Dr K K Aggarwal,

President CMAAO, HCFI, Past National President IMA, Chief Editor Medtalks