Health Officer Order: Outpatient COVID-19 Treatment in Skilled Nursing Facilities
As of July 27, 2022, over half of the 342 skilled nursing facilities (SNFs) in LA County are experiencing active COVID-19 outbreaks, which is the highest level of transmission since the surge last winter. All patients in SNFs are at high risk for progressing to severe COVID-19 if infected. Fortunately, there are now outpatient COVID-19 treatments such as oral antivirals that are easy to administer and can reduce the risk of poor outcomes, including hospitalization and death. Despite the wide availability of oral antivirals, they continue to be underutilized in the nursing home population.
To close this crucial gap and significantly improve outcomes in this vulnerable population, Public Health issued an update on July 25, 2022 to the Order of the Health Officer for Control of COVID-19: Prevention of COVID-19 Transmission in Skilled Nursing Facilities requiring all SNF patients with a positive SARS-CoV-2 viral test to be immediately assessed by their healthcare provider for any symptoms of COVID-19. Oral COVID-19 antivirals should be initiated at the facility within 5 days of symptom onset if clinically appropriate, i.e., they have mild or moderate symptoms and there are no contraindications. Please do not transfer residents to hospitals solely for treatment of mild or moderate COVID-19. These residents should be treated at their SNF.
In addition to this updated Health Officer Order, Public Health is working on the following to increase use of oral antivirals in nursing homes:
- Ensuring long-term care pharmacies have access to oral antivirals and other outpatient COVID-19 treatments.
- Training SNF staff on a streamlined protocol for accessing oral antivirals.
- Educating SNF staff on outpatient COVID-19 treatment via multiple webinars.
Since the oral antivirals Paxlovid (ritonavir-boosted nirmatrelvir) and molnupiravir must be taken within 5 days of symptom onset, all healthcare providers working with SNFs should ask to be notified immediately of any patients who test positive for SARS-CoV-2, especially when the facility is in an active outbreak. Even asymptomatic infected patients could be considered for an advance oral antiviral prescription should any symptoms develop later. Furthermore, it is highly recommended for providers to work with their SNFs in contacting medical decision makers to discuss oral antiviral treatment in advance of potential outbreaks and/or infections. Wherever possible, providers should obtain written advance consent to expedite the process and ensure this high-risk patient population can obtain effective treatment in time.
Of note, Paxlovid has significant drug-drug interactions given the ritonavir component and needs to be renally dosed. Thus, providers must carefully review the patients’ medication lists while utilizing a drug interaction tool (see resources below), review latest laboratory blood work, and/or work with the facility’s pharmacist prior to prescribing.
For more resources on oral COVID-19 antivirals, please see the following: