Real-world evaluation of the impact of two anti-SARS-CoV-2 monoclonal antibody regimens on COVID-19 hospitalizations in older adults.

Evidence from clinical trials suggest anti-SARS-CoV-2 monoclonal antibodies (mABs) may reduce coronavirus disease 2019 (COVID-19)-related hospitalizations. The purpose of this study was to assess the real-world impact of mAB administration on COVID-19 hospitalization among patients 65 years or older. This was a retrospective, propensity-matched cohort study that included patients aged 65 years and older who presented to the emergency department (ED) within 10 days of symptom onset of mild to moderate COVID-19 infection. Outcomes were compared between those who did and did not receive mAB therapy. The primary endpoint was the rate of hospitalization for COVID-19 within 30 days of index ED visit. A total of 137 patients receiving mABs were matched to 137 controls. Hospitalization occurred in 2.9% of mAB-treated patients compared to 14.6% of patients of the standard of care (SOC) arm (odds ratio: 0.20 [95% CI: 0.07-0.59]). There were zero intubations and zero deaths compared to 3 (2.2%) and 2 (1.5%) in the SOC group. Among the 223 patients receiving mAB in the overall cohort, adverse drug events occurred in 10 (4.5%). Treatment with mAB therapy for mild to moderate COVID-19 was associated with a substantially reduced risk of hospitalization among patients at least 65 years of age.

Improving the Flow: Optimization of Available Triage Standing Medication Orders in the Pediatric Emergency Department.

BACKGROUND: Emergency department (ED) overcrowding has led to longer waits for patients to be seen, treated, and released. This has been coupled with an increased number of patients who leave without ever being seen by an ED provider. Improving patient throughput and decreasing ED patient length of stay while continuing to provide high-quality care is of paramount importance. Optimization of available standing orders for fever, pain, and/or nausea and vomiting at the time of nurse triage may offer an opportunity to improve patient outcomes, decrease time to medication (TTM) administration for ill and injured patients, and decrease length of stay. PATIENTS AND METHODS: This was a retrospective cohort patient analysis for patients younger than 18 years of age presenting to the ED before (February 2019) and after (February 2020) an intensive campaign aimed at educating the triage nurses regarding the use of ED standing orders for acetaminophen, ibuprofen, and ondansetron. The investigators sought to evaluate percentage change in nurse triage-initiated (NTI) orders between the 2 time frames. Secondary outcomes evaluated TTM, documented adverse effects, percentage of inappropriate medication administrations, and correlate TTMs to ED discharge. RESULTS: The percentage of patients who received an NTI medication was 49% in 2019 and 58% in 2020 (P = 0.257). For NTI orders, TTM initiation decreased in the postintervention group from an average of 45 minutes down to 37.6 minutes. In the overall cohort, TTM administration in the NTI group was a mean of 41.2 minutes compared with 75.9 minutes in the provider-initiated group (P < 0.0001). Length of stay was the same for the NTI versus the provider-initiated group in overall cohort (134.4 vs 142.9, P = 0.4303). No adverse events were identified. CONCLUSIONS: Nurse-initiated medication administration at the time of triage offers an opportunity to get patients vital treatment more quickly. Medications administrated earlier in the pediatric ED encounter have a correlation to improved throughput and higher possibility of quicker discharge from the ED. Further research is needed to fully assess the impact of continuing education on improving utilization of triage standing orders and the impact on ED throughput.

Real-World Observational Review of Andexanet Alfa Prescribing and Utilization Outcomes at a Community Teaching Hospital.

OBJECTIVES: Andexanet alfa is the first approved antidote in the management of life-threatening bleeds in patients treated with Xa inhibitors. The ANNEXA-4 study was successful in reducing factor Xa levels during time of administration but lacked correlation to improved patient outcomes. Given its novel mechanism of action, U.S. boxed warning, cost of up to $58,000 per dose, and limited efficacy data compared with standard of care, hospitals are faced with a dilemma with its addition to formulary and process for ensuring optimized use. The objective of this study was to evaluate adherence to institution restriction criteria and the clinical outcomes of treatment for patients for whom andexanet alfa is requested. DESIGN: Retrospective cohort study of andexanet alfa requests within a 12-month time period. SETTING: A 600-bed community teaching hospital. PATIENTS: Patients whom pharmacists received request for dispensing andexanet alfa. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Quality outcomes reviewed compliance to restriction criteria. Clinical outcomes evaluated use of adjunctive blood products, ICU length of stay, hospital length of stay, and hospital mortality. Safety outcomes evaluated incidence of thrombotic events.Andexanet alfa was requested for 16 patients from November 2018 to November 2019. It was administered in nine patients, with compliance to restriction criteria of 66.6%, average ICU length of stay 5.6 days, hospital length of stay 8.6 days, hospital mortality in 44.4%, and thrombotic events in 33.3%. Orders were rejected in seven patients with compliance to restriction criteria of 100%, ICU length of stay 3.2 days, hospital length of stay 5.5 days, hospital mortality in 14%, and thrombotic events in 14%. CONCLUSIONS: A greater rate of adverse effects and mortality was identified with the use of andexanet alfa compared with clinical trials. This is potentially due to its use in a more severely ill patient population and lack of adherence to restriction criteria.

Abrupt versus gradual cessation of steroids in patients with septic shock.

PURPOSE: To determine if a difference in hemodynamic stability would be identified in patients with abrupt withdrawal of steroids compared to patients who underwent a taper. MATERIAL AND METHODS: This retrospective cohort study identified patients who received vasopressors followed by IV hydrocortisone for treatment of septic shock from January 1, 2013 until January 1, 2015.The primary endpoint evaluated the percent of patients requiring vasopressor re-initiation during taper and 72 h following taper, or 72 h directly following abrupt withdrawal. Secondary endpoints evaluated include glycemic control, and ICU length of stay. RESULTS: A total of 87 patients were included for final analysis. Of the 87 patients, 7 out of 41 patients (17.1%) in the steroid taper group developed hemodynamic instability and required re-initiation of vasopressors compared to 1 out of 46 patients (2.2%) in the abrupt withdrawal group (p = 0.024). Patients in the taper group also had worse glycemic control (125.1 mg/dL abrupt vs. 150.8 taper; p < 0.001). There was no statistical difference found in the ICU length of stay (8.28 days abrupt vs.10.73 taper; p = 0.14). CONCLUSION: The abrupt withdrawal of steroids in patients with resolving septic shock did not impact hemodynamic stability and offers an opportunity to reduce medication burden and reduce adverse drug reactions.