Roper St. Francis

Monoclonal Antibody Infusion

Referral screening sheet

 

The patient must meet the following criteria to be considered a candidate for infusion:


  • Positive COVID test result which is documented in the RSFH health record OR a paper copy of the positive test (Home test results will NOT be accepted).
  • RSFH is scheduling patients as close to possible within 5 days of symptom onset based on limited drug availability and chair access.

 
First Name:*
Last Name:*
Date of Birth
(mm/dd/yyyy):*
Patient Cell Phone #:*
 
Referring Physician Name:*
Referring Physician Phone Number:*
 
Does the patient weigh ≥ 40 kg?
Is the patient currently requiring oxygen therapy or an increase to chronic oxygen due to COVID-19?
 
Vaccination status:*


Has a booster been administered?
 
Date onset of symptoms:
(mm/dd/yyyy):*
(Common symptoms include: fever, dry cough, fatigue. Less commonly, loss of taste or smell, aches and pains, headache, sore throat, nasal congestion/runny nose or diarrhea may also be experienced)
COVID-19 positive result date:
(mm/dd/yyyy):*
 
Test type:*
 
Does the patient have any of the following conditions:
Current Pregnancy

Please select one of the following tiers that best describes your patient based on age, the presence of immunocompromising conditions and clinical risk factors that increase the risk of developing severe Covid (see below).

Patient selection for drug allocation will be based on patient tier and supply of available drug.

 

Risk Prioritization Tiers:

  • Immunocompromised individuals (see below) not expected to mount an adequate immune response to COVID-19 vaccination or SARS-CoV-2 infection due to their underlying conditions, regardless of vaccine status
  • Unvaccinated individuals at the highest risk of severe disease, meeting at least one of the following: ≥ 75 years; ≥ 65 years with any clinical risk factors
  • Pregnant persons, partially vaccinated (no booster)
  • Unvaccinated individuals at risk of severe disease not included in Tier 1 AND meeting at least one of the following: ≥ 65 years; < 65 years with any clinical risk factors
  • Pregnant persons, fully vaccinated (with booster)
  • Vaccinated individuals at high risk of severe disease (meeting at least one of the following: anyone ≥75 years or anyone ≥65 years with clinical risk factors)
  • Vaccinated individuals at risk of severe disease (anyone ≥65 years or anyone <65 with clinical risk factors)
 

Severe Immunocompromising Conditions:

  • Patients within 1 year of receiving B-cell depleting therapies (e.g., rituximab, ocrelizumab, ofatumumab, alemtuzumab)
  • Patients receiving Bruton tyrosine kinase inhibitors
  • Chimeric antigen receptor T cell (CAR-T) recipients
  • Post-hematopoietic cell transplant recipients who have chronic graft versus host disease (GVHD) or who are taking immunosuppressive medications for another indication
  • Patients with hematologic malignancies who are on active therapy
  • Lung transplant recipients
  • Patients who are within 1 year of receiving a solid-organ transplant (other than lung transplant)
  • Solid-organ transplant recipients with recent treatment for acute rejection with T or B cell depleting agents
  • Severe combined immunodeficiencies
  • Untreated HIV with a CD4 cell count <50 cells/mm3

Clinical Risk Factors:

  • Adult patient BMI ≥ 25 kg/m2 or pediatric patient > 85th percentile for age & gender
  • Immune compromising condition other than Tier 1a severe immune compromising condition
  • Cancer other than Tier 1a hematologic malignancies
  • Diabetes mellitus, type 1 and 2
  • Chronic kidney disease, i.e. at least stage 3 or GFR < 60 mL/min
  • Chronic lung disease, e.g. COPD, asthma
  • Neurodevelopmental disorders, e.g. cerebral palsy, genetic, metabolic
  • Cerebrovascular disease, e.g. stroke
  • Chronic liver disease, e.g. cirrhosis, alcoholic liver disease
  • Heart conditions, e.g. heart failure, coronary artery disease, cardiomyopathies
  • Hypertension
  • Medical-related technology dependence, e.g. tracheostomy, gastrostomy
  • Mental health disorders, e.g. mood disorders, schizophrenia spectrum disorders
  • Sickle cell disease
  • Smoking, current or former