Eric Ruderman, MD - Infusions In The Time Of Corona Save

Hi, I'm Jack Cush with RheumNow. I'm here with Doctor. Eric Gruderman from Northwestern Medical Group. If you hadn't seen it, you need to read it. Eric wrote a great blog last week in RheumNow entitled Infusions in the Time of Corona.

Eric, I'm glad you're here. We want to discuss this and teach people what to do. How are you this morning?

It's, great Jack. I'm doing alright. We're kind of struggling our way through this. We're all learning as we go.

That's right. It is. I think that's the attitude, right? I mean, there's a lot of unknowns, but the day that the idea is to get through each day and learn a little bit more each day in three weeks we're going to be experts at all of this, right? You know right now we're just sort of, sort of feeling our way.

So again your, idea of rethinking how we do infusions is really important. How the discussion come up at your site?

You know, what happened was we started a little over a week ago trying to figure out how we could keep patients out of the office. We didn't want people, because our office is in the office building attached to the hospital, we didn't want people down there. And so we moved to, telehealth visits for all of our office visits, but we realized that infusion is obviously not something you can do remotely. Our infusion center is adjacent to our clinic. And we began to sort of think about ways that we could structure the infusion center and manage it to try to maintain, as much of a safe environment as we could.

We started to look at who was coming in, what they were coming in for, looked at our setup and infusion and sort of went through everything to try to figure out, we knew we had to keep giving infusions to these patients, but how can we do it in the safest manner possible?

Okay, so at the top of the list is social distancing. I'm sure your infusion suites a lot like ours crammed in there for efficiency and you know the more infusions any one nurse does at a time, the more profitable infusion center is going to be. So what was your approach to spacing out each, infusion chair?

Yeah, so we looked at, so we have eight chairs and you're right, they're right sort of next to each other and the first thing we did was the way the room was structured. We were able to move two chairs out. So we went down to six chairs, which kept people far enough away from them. I mean, to be frank, we didn't think about profitability. Our first issue was safety, which, you know, we have the luxury because I'm part of a university practice, and so it's a bigger practice.

I think this is going be a bigger deal for some people who are, running a smaller private practice because obviously, the dollars and cents matter more. But for us, we didn't really think so much about billing, more about just sort structuring the infusion center. It was interesting because we were able to sort of spread the chairs within the room. We also have more open exam rooms now because we're not bringing patients in for live visits. That opened up the exam rooms, but there's this sort of balance because when a patient is somewhere in an exam room, then the nurse is not there to kind of monitor the infusion.

And so for some things it's reasonable, for other things we thought, well, that's not the best move. So it was really sort of trying to balance everything.

So what happened as far as staffing within the clinic?

So in the clinic, we went pretty quickly to a 100% telehealth visits. We told the docs to stay home and do their visits from home. That meant that we had to have somebody in the clinic every day to have somebody on-site for infusions. And so we set up a rotation and I have one physician in the clinic, either doing other work or doing their telehealth visits from a clinic computer, but they're available, if the infusion center needs them. Infusion center is staffed by nurses.

We've got four nurses and an MA, and they kept coming. Had because we obviously we need to have that staffed up appropriately. It doesn't do us a lot of good to try to staff down and then people are there longer. So the idea was to sort of make sure we had sufficient staff. Somebody came in, if they were there for a thirty minutes, you know, Actemra infusion, they got it and left.

They didn't stick around longer than, you know, we wanted people in and out as quick as they could, they didn't spend a lot of time in the facility. Well,

and what do you think about compartmentalizing those four nurses as far as you work these three chairs, she works those two chairs, etc. As a way of limiting their interaction because the problem is that the nurses themselves become vectors and are they wearing PPE to protect themselves and to protect, other patients?

Yeah, they're not wearing full on PPE and we are trying to kind of keep them to, you know, an individual patient as much as possible. And it's hard because particularly with some of the longer infusions, the patient get Rituxan, you know, they're there for six hours and it's hard to have one nurse be the only person touching them for six hours. We try that to a certain extent. We screen everybody when they check-in, if they have any symptoms, fever, cough, anything, they're shunted to an exam room and checked out first before they go in the back. And so that's not been an issue.

We've had a couple people with absolutely no symptoms who had a temperature of 99.3 and felt totally fine, had no particular risk that we were aware of. And we had them go to an exam room, put a mask on them, and sort of kept them separate from the other patients just out of an abundance of caution. But anybody who really was of concern, cough or fever, we either sent them back home, or based on the protocols that the hospital set up, they were sent elsewhere for screening if it was really appropriate.

So one of the good things about continuing your infusions is that you number one, stay in touch with the patient, and provide education COVID because they can get a lot of questions asked by the doctor in residence or the nurses taking care of them but they also are going to stay keep control of their disease and you can reinforce the need for therapy. So by giving the therapies you're giving them, have you changed any of those? So they're infeasible for taxane, Remicade, Rincea, Atemra, Prolia, what have you done with those as far as,

so what are you doing? Yeah, it's a great question. So, mean, was the other thing we did. We first sat down, we said, all right, we need to, you know, separate out the chairs. But as soon as we separated the chairs, now we've got six chairs instead of eight chairs, which means our capacity is down by 25%.

And we were not 100% full, but pretty close. We were running about 90% full. We had a pretty busy infusion center. And so the first thing we did was we knocked out all the infusions that weren't critical. So we don't do any re class right now.

We knocked out we do infusions for other, basically all the non oncologic infusions in the institution. So we said no more iron for the time being. And the stuff that really wasn't important and really sort of honed in on the biologics that people were taking for, you know, immune mediated diseases. The next thing we did was sort of look at whether the number of infusions they were getting and the frequency could be modified at all. So we looked at things that were monthly infusions, Ectembra, Erencia, Benlysta even, in people who are really stable, who've been on it for quite a while, and we're trying to spread those out to six weeks.

You know, we'll see if it works. I'm hoping that in a stable patient, that's going to be it, but we're trying to do everything we can. As you said at the top, we're learning as we go. And, you know, it may be that we find out that's not a good plan, and we do need to do every four weeks, but we're hoping that and there is, you know, evidence that people can start to spread their biologics. We looked at the Rituxan.

Rituxan's a big infusion for us because we do everybody. So we get a lot of, GPA patients, some RA patients, not so many, a lot of interstitial lung disease from pulmonary for various reasons. They kind of like rituximab for that population. And so we, you know, we're continuing to do it, but some of these patients were getting two infusions every six months instead of one. And I think we're going to try to go with one and hope for the best there.

Again, there's evidence that you may not need both each time. We're not spreading them because we want to be cautious about that, but at least, you know, getting rid of that second one, which opens up a chair for six hours. So that's important.

So let me clarify the Rituxan, your usual Rituxan would be let's say a thousand and then repeat it two weeks later with another thousand and then you're doing that at some interval either every six months or every, every twelve months. Now you're just going to do the one thousand one time.

Yeah, so for the initial infusion, we're doing the one thousand times two, but we're going to try, you know, and this is in conjunction with the docs. We're talking to everybody who's prescribed this, and some feel uncertain about doing that, but for somebody who may be getting a thousand times two every six months, at least for the next one, if it's coming up in the next month or so, we're gonna go with a thousand times one, and that frees up a second infusion. Hopefully that will be fine if it is, and we can always add another one if we need to, but we're going try to, you know, we're doing everything we can to kind of cut down the number of infusions so we have the, so the traffic is cut down as much as possible. With any of

these drugs, are you changing the dose? We kind of changed the dose there on Rituxan. Any others where you're changing dose, you're giving it a little more Remicade or you go into eight milligrams per kilogram of tocilizumab and then hoping you can give it less?

We haven't been that's what we're looking at most of our tocilizumab patients are on the eight milligrams per kilogram anyhow. So we really haven't been but I mean, that's something we certainly can look at. We are changing the infusion time. So we've moved to, ninety minutes for infliximab instead of two hours or two and a half hours. We had been talking about that for a while because there's, you know, some evidence, particularly from the gastroenterologist that you can get away with shorter, interval infusions, especially in somebody who's been on it for a bit and has had enough infusions.

This kind of pushed us to do that again, because it gets people in and out quicker, so they spend less time in the infusion center.

Okay, last question is what are you doing about new biologic starts as far as infusions?

We're doing them. I think, you know, that's a learn as you go process. I think there are some that we're pushing off. I had a patient of my own recently who's Crohn's patient who has ankylosing spondylitis and the plan was to start him on infliximab. He had just gotten approval, got on the phone with him the other day, talked to a guest neurologist and we're gonna put him on adalimumab instead.

Cause I just thought that, you know, in somebody who hasn't been on anything yet, it makes more sense to try a non infusion right now, again, instead of decrease the density, in our infusion center. But for anybody who needs treatment, they need treatment. So we're going to

have to keep going. Doctor. Eric Ruman, thank you for taking the lead on this. Eric will be in touch.

All right. Thanks,

Jack. Bye bye.