Monoclonal Antibodies for COVID Patients: One System’s Experience

The success of monoclonal antibodies in treating COVID-19—by reducing the chance of hospitalization—has led to these IV treatments being administered by EMS personnel at long-term care homes.

The downside to these treatments is that they are time-consuming to give and to monitor afterward for adverse reactions. This is why Geisinger Health System in Danville, Pa., has developed innovative ways for paramedics to facilitate their administration safely while reducing demands on their time.

Douglas Kupas, MD, is an EMS physician, emergency physician, and paramedic. He serves as director of Geisinger’s mobile integrated healthcare (MIH) program. He spoke recently with EMS World to share Geisinger’s approach. The MIH program employs Geisinger paramedics in four vehicles across 19 counties in north-central and northeastern Pennsylvania.

EMS World: Tell us about the MIH program’s approach to facilitating monoclonal antibodies via EMS and how it has evolved.                           

Kupas: We initially considered doing what MIH does with pretty much all our other programs, which is going to patients’ homes one-on-one when somebody was COVID-positive and administering this medication. The issue that became apparent very quickly was that it is very time-consuming to do it this way. The infusion takes an hour, and there’s a required one-hour monitoring afterward for any allergic reactions. On the front end, you have to start the IVs. You have to obtain the medication. You have to travel to and from the patient’s home. All told, it could easily turn into a 4–6-hour deal per patient.

We soon realized it really wasn’t feasible to do these one-on-one. So we came up with two options to administer these infusions far more efficiently without compromising patient safety.

What was the first?

The first option is done with paramedics in conjunction with skilled nursing homes. We go to a nursing home and team with their staff to administer the monoclonal antibodies to 3–6 patients over the same period. This makes the process much more efficient.

To further reduce demands on our paramedics’ time, the skilled nursing facility identifies the patients who are candidates and obtains consent. It then orders the medication from the pharmacy, because a pharmacist has to prepare it. So the pharmacist prepares the batches of monoclonal antibodies, and our MIH paramedics pick them up, using the MIH squads equipped with refrigerators.

Once at the nursing facility, our paramedic starts all the IVs on the patients. One of the nurses from the facility then follows right behind them, setting up and starting the infusion and then monitoring patients along with the paramedic in case of an anaphylactic reaction. In this way a single MIH paramedic can have several patients getting their one-hour infusion and being watched for allergic reactions at the same time. We have found this approach to be the most efficient way to do this.

Meanwhile, your outpatient approach uses tents?

It does, namely high-end tents like the military models that have HVAC and flooring. We have these tents at eight of our emergency departments. For monoclonal antibody infusions we use these ED tents in four different counties.

First our laboratory identifies all patients with recent positive COVID tests, and case managers determine which patients are eligible for treatment. They then schedule them to come to the tent for a group treatment. Next the paramedic is teamed with a nurse from our infusion therapy program. Like our SNF administrations, the paramedic starts all IVs, monitors the patients, and is prepared for treatment of allergic reactions, while the infusion nurse runs the medications. Our MIH paramedics do their documentation in the same Epic record used for all patient care in our system, so they document this care in a way that is visible to everybody who cares for the patients.

Why is monitoring for allergic reactions so important?

The monoclonal antibodies being given right now are under an emergency use authorization. This means studies have been done, but they’ve been given an FDA clearance that recognizes them as experimental. Other antibody treatments used in medical care have been associated with allergic reactions, and these medications have also led to rare allergic reactions.

This is the same experimental treatment President Trump received when he contracted COVID-19. They’re now available to appropriate patients across the country who meet specific indications.

The initial monoclonal antibodies study reported one allergic reaction in more than 300 patients. We don’t really know, if we give this to thousands and thousands of patients, what the true rate of allergic reaction will be. We had one infusion stopped when a patient became anxious. We have not had any reactions that required treatment with epinephrine or any other medications, but the MIH team is prepared for this.

I can tell you that in our program we have not had any allergic reactions thus far. But most of the time when somebody is getting a new infusion of, for example, an antibiotic, it’s recommended that you do it in the presence of somebody who’s able to treat a severe allergic reaction. The paramedics are perfect for this role because they have protocols for anaphylaxis and allergic reactions. They also have epinephrine, diphenhydramine, and the intravenous fluids to treat an allergic reaction.

What kind of training did you have to do with your people to make this work?

Actually, training wasn’t an issue because our paramedics already know how to do all the tasks associated with this treatment. It was the logistics. There are a lot of moving parts involved in making this work, from having a physician/advanced practitioner at the nursing home to identifying the patients to be treated, placing the orders and coordinating with a pharmacy that can then prepare them for pickup, and making all this come together. This approach does not even need a specific type of paramedic. As we started doing infusions at multiple ED tents and SNFs on the same day, we have used any paramedic within our system who volunteered for overtime to work at the tents. In addition to our MIH paramedics, we’ve also used our ground 9-1-1 paramedics and our Geisinger Life Flight paramedics and flight nurses.

How long have you been applying your processes, and how many cases have you handled to date?

We started on November 23. We started small to test our logistics, doing two patients on our first SNF visit, but we now do up to six patients at a time on a SNF visit.

The ones that we do in the community at the tents are not nursing home patients. Those are patients who make an appointment and come to the tent. There we are able to accommodate about eight a day. Last Friday we did 16 patients in two ED tents and one SNF on the same day.

Over our first four weeks, we have helped to administer monoclonal antibody therapy for 70 patients—33 at four different SNFs and 37 in four different community tents.

Perhaps it’s too early to ask, but have you learned any lessons already from the period you’ve been running that we can pass onto other EMS agencies?

Absolutely. Lesson No. 1 is that EMS is perfectly structured—especially mobile integrated healthcare and community paramedic programs—to be able to do these programs. We bring a lot of the skills that are needed to augment, for example, a nurse at a nursing home and being able to do this treatment for multiple patients at a time.

Lesson No. 2 is that this kind of program is a heavy lift logistically. It sounds like a really simple thing to do, but getting all those moving parts together so the patients are consented and you’re not wasting a medication after it’s been mixed, and getting a nursing home with the right number of patients who can be treated at the same time, isn’t easy.

The same is true for the tent. We have to make a lot of phone calls to fill our tent with eight people a day.

The good news is that any paramedic has the skills to do this job. Moreover, by paying some of our paramedics overtime to work at the tent, we can free up our MIH vehicle to administer treatments at nursing homes. This will allow us to run both options simultaneously while still attending to our regular MIH patient referrals.

James Careless is a freelance writer and frequent contributor to EMS World.