Does a Pharmacist-Driven Protocol Increase Appropriate Prescribing of Rabies Postexposure Prophylaxis?

BACKGROUND: Human rabies can be prevented through postexposure prophylaxis (PEP). Although the case fatality rate is high, there are only one to three human cases per year in the United States. Despite the low incidence, the cost of rabies diagnostics, prevention, and control is significant. Recommendations exist regarding which patients should receive PEP, though several studies demonstrate a high frequency of unnecessary prescribing of PEP. OBJECTIVE: The purpose of this study is to determine if an animal bite protocol improves compliance with state and national recommendations regarding treatment of patients presenting to the emergency department (ED). Potential cost savings will also be evaluated. METHODS: An institutional review board-approved, single-center, retrospective chart review was conducted from January 1, 2017 to March 18, 2018 to evaluate patients presenting to the ED with an animal bite prior to and after implementation of a protocol. The primary outcome was defined as the percentage of PEP offered as indicated by the protocol. Secondary outcomes included the appropriateness of not offering PEP and estimated cost savings after protocol implementation. RESULTS: PEP was indicated four times out of 29 offers pre-protocol and three times out of five offers post-protocol (p = 0.0476). There was no difference in the appropriateness of not offering PEP (pre-protocol 105/107 times vs. 29/29 times; p = 0.9998). Cost savings was associated with protocol implementation. CONCLUSION: A pharmacist-driven protocol can beneficially influence prescribing habits after potential rabies exposure and is associated with cost savings.

Engagement in local and collaborative wildfire risk mitigation planning across the western U.S.-Evaluating participation and diversity in Community Wildfire Protection Plans.

Since their introduction two decades ago, Community Wildfire Protection Plans (CWPPs) have become a common planning tool for improving community preparedness and risk mitigation in fire-prone regions, and for strengthening coordination among federal and state land management agencies, local government, and residents. While CWPPs have been the focus of case studies, there are limited large-scale studies to understand the extent of, and factors responsible for, variation in stakeholder participation-a core element of the CWPP model. This article describes the scale and scope of participation in CWPPs across the western United States. We provide a detailed account of participants in over 1,000 CWPPs in 11 states and examine how levels of participation and stakeholder diversity vary as a function of factors related to planning process, planning context, and the broader geographic context in which plans were developed. We find that CWPPs vary substantially both by count and diversity of participants and that the former varies as a function of the geographic scale of the plan, while the latter varies largely as a function of the diversity of landowners within the jurisdiction. More than half of participants represented local interests, indicating a high degree of local engagement in hazard mitigation. Surprisingly, plan participation and diversity were unrelated to wildfire hazard. These findings suggest that CWPPs have been largely successful in their intent to engage diverse stakeholders in preparing for and mitigating wildfire risk, but that important challenges remain. We discuss the implications of this work and examine how the planning process and context for CWPPs may be changing.

Cell-mediated and humoral immune responses to bovine herpesvirus type 1 and bovine viral diarrhea virus in calves following administration of a killed-virus vaccine and bovine herpesvirus type 1 challenge.

OBJECTIVE To evaluate cell-mediated and humoral immune responses of calves receiving 2 doses of a dual-adjuvanted vaccine containing inactivated bovine herpesvirus type 1 (BHV1) and bovine viral diarrhea virus types 1 (BVDV1) and 2 (BVDV2) before and after exposure to BHV1. ANIMALS 24 Holstein steers negative for anti-BHV1 antibodies and proliferative cell-mediated immune responses against BHV1 and BVDV. PROCEDURES Calves were randomly assigned to 3 groups. The vaccinated group (n = 10) received 2 doses of vaccine on days 0 and 21. Control (n = 10) and seeder (4) groups remained unvaccinated. Calves were commingled during the study except for the 3-day period (days 53 to 55) when seeders were inoculated with BHV1 (1.04 × 107 TCID50, IV) to serve as a source of virus for challenge (days 56 through 84). Rectal temperature and clinical illness scores were monitored, and blood and nasal specimens were obtained for determination of clinicopathologic and immunologic variables. RESULTS After BHV1 challenge, mean rectal temperature and clinical illness scores were lower for vaccinates than controls. In vaccinates, antibody titers against BHV1 and BVDV2, but not BVDV1, increased after challenge as did extracellular and intracellular interferon-γ expression, indicating a T helper 1 memory response. Additional results of cell marker expression were variable, with no significant increase or decrease associated with treatment. CONCLUSIONS AND CLINICAL RELEVANCE Calves administered 2 doses of a killed-virus vaccine developed cell-mediated and humoral immune responses to BHV1 and BVDV, which were protective against disease when those calves were subsequently exposed to BHV1.

The Impact of an Emergency Department Front-End Redesign on Patient-Reported Satisfaction Survey Results.

INTRODUCTION: For emergency department (ED) patients, delays in care are associated with decreased satisfaction. Our department focused on implementing a front-end vertical patient flow model aimed to decrease delays in care, especially care initiation. The physical space for this new model was termed the Flexible Care Area (FCA). The purpose of this study was to quantify the impact of this intervention on patient satisfaction. METHODS: We conducted a retrospective study of patients discharged from our academic ED over a one-year period (7/1/2013-6/30/2014). Of the 34,083 patients discharged during that period, 14,075 were sent a Press-Ganey survey and 2,358 (16.8%) returned the survey. We subsequently compared these survey responses with clinical information available through our electronic health record (EHR). Responses from the Press-Ganey surveys were dichotomized as being "Very Good" (VG, the highest rating) or "Other" (for all other ratings). Data abstracted from the EHR included demographic information (age, gender) and operational information (e.g. - emergency severity index, length of stay, whether care was delivered entirely in the FCA, utilization of labs or radiology testing, or administration of opioid pain medications). We used Fisher's exact test to calculate statistical differences in proportions, while the Mantel-Haenszel method was used to report odds ratios. RESULTS: Of the returned surveys, 62% rated overall care for the visit as VG. However, fewer patients reported their care as VG if they were seen in FCA (53.4% versus 63.2%, p=0.027). Patients seen in FCA were less likely to have advanced imaging performed (12% versus 23.8%, p=0.001) or labs drawn (24.8% vs. 59.1%, p=0.001). Length of stay (FCA mean 159 ±103.5 minutes versus non-FCA 223 ±117 minutes) and acuity were lower for FCA patients than non-FCA patients (p=0.001). There was no statistically significant difference between patient-reported ratings of physicians or nurses when comparing patients seen in FCA vs. those not seen in FCA. CONCLUSION: Patients seen through the FCA reported a lower overall rating of care compared to patients not seen in the FCA. This occurred despite a shorter overall length of stay for these patients, suggesting that other factors have a meaningful impact on patient satisfaction.