Avoidable emergency department visits for rabies vaccination.

BACKGROUND: Administering subsequent doses of rabies vaccine is not a medical emergency and does not require access to emergency department (ED) services. This study reviewed ED visits for rabies postexposure prophylaxis (PEP) to identify avoidable ED visits for subsequent rabies vaccination. METHODS: This retrospective study included patients who received human rabies immune globulin (HRIG) or rabies vaccine at 15 EDs of a multi-hospital health system from 2016 to 2018. All ED visits were classified as initial or non-initial healthcare visits after animal exposure. Emergency department visits for non-initial healthcare were classified as necessary (HRIG administration, worsening symptoms, other emergent conditions, or vaccination during a natural disaster) or avoidable (rabies vaccination only). RESULTS: This study included 145 patients with 203 ED visits (113 initial and 90 non-initial healthcare visits). Avoidable ED visits were identified for 19% (28 of 145) of patients and 66% (59 of 90) of ED visits for non-initial healthcare. Contributing factors for avoidable ED visits were suboptimal ED discharge instructions to return to the ED for vaccination (n = 20 visits) and patients' inability to coordinate outpatient follow-up (n = 17 visits). Patients with previous avoidable ED visits had a 73% probability for unnecessarily returning to the ED for vaccination. The average number of avoidable ED visits observed per patient was 0.41 (95% CI = 0.25 to 0.56). Since the Centers for Disease Control and Prevention reports that 30,000 to 60,000 Americans initiates rabies PEP each year, we estimate that 7500 to 33,600 avoidable ED visits occur for rabies vaccination in the US each year. CONCLUSIONS: One of 5 patients who received rabies PEP in the ED had avoidable ED visits for subsequent rabies vaccination. This study highlights systemic lack of coordination following ED discharge and barriers to accessing rabies vaccine.

Wound characteristics and infiltration with immune globulin for rabies postexposure prophylaxis in the emergency department.

OBJECTIVE: This study described characteristics of wounds caused by animal exposures and evaluated patient factors and wound factors associated with wound infiltration of human rabies immune globulin (HRIG). MATERIALS AND METHODS: This retrospective cohort study evaluated wound characteristics among patients who had visible wounds and received HRIG or rabies vaccine for rabies postexposure prophylaxis (PEP) at 15 emergency departments from May 2016 to June 2018. RESULTS: Of 110 included patients (9 children, 82 adults, and 19 older adults), 21% (n = 23) had ≥2 wounds, and 10% (n = 11) had infected wounds. Twenty-eight (25%) patients had severe wounds, defined as receiving sutures (n = 20) or reaching subcutaneous tissue or bone (n = 20). Wounds were present on upper extremities for 42% (n = 46) of patients, lower extremities for 35% (n = 38), head/face for 3% (n = 3), and in multiple locations for 21% (n = 23). Wounds were < 3 cm in length for 64% (n = 70) of patients. Puncture wounds were present in 60% (n = 66) of patients, abrasions in 45% (n = 49), and lacerations in 38% (n = 42). Among 108 wounds from 82 patients with documented HRIG administration sites, 57% (n = 62) of wounds received HRIG infiltration. Infiltration occurred less frequently for wounds on the face/head/torso (adjusted odds ratio [aOR] = 0.07, 95% confidence interval [CI] = 0.01 to 0.49), wounds on hands/fingers (aOR = 0.20, 95% CI = 0.06 to 0.65), and abrasion-only wounds (aOR = 0.26, 95% CI = 0.08 to 0.80) after adjusting for age. CONCLUSIONS: Upon presentation for rabies PEP, most patients did not have severe wounds and did not require emergency services or complex wound management. Wounds on the face, head, torso, hands, or fingers and abrasions were less likely to receive HRIG infiltration.

Implementation of Clinical Decision Support on Emergency Department Delivery of Human Rabies Immune Globulin.

Importance: Fatal human rabies infections can be prevented through appropriate rabies postexposure prophylaxis (PEP). Errors in patient selection and administration of human rabies immune globulin in the emergency department (ED) setting were identified in a previous study of rabies PEP administration. Objective: To test the a priori hypothesis that implementation of a rabies PEP bundle in the ED would improve full adherence to 6 human rabies immune globulin quality indicators compared with preimplementation controls. Design, Setting, and Participants: This quality improvement study was conducted in 15 EDs in a US multihospital health system. Patients who received human rabies immune globulin or rabies vaccine in the ED from January 2015 to June 2018 were included in the preimplementation control group and from December 2019 to November 2020 were included in the postimplementation intervention group. Data were analyzed in January 2021. Exposure: The PEP bundle was implemented in December 2019 and consisted of electronic health record enhancements, including clinical decision support, ED staff education, and patient education. Main Outcomes and Measures: Full adherence to 6 human rabies immune globulin quality indicators: patient selection, dose, timing, infiltration into wounds, administration distant from rabies vaccine site, and administration that avoids the buttock. Results: The study included 324 patients; 254 patients were in preimplementation group (mean [SD] age, 39 [21] years; 135 [53%] women) and 70 in the postimplementation group (mean [SD] age, 38 [19] years; 33 [47%] women). Most patients presented to EDs embedded in a community hospital (231 patients [71%]). Full adherence increased from 37% in the preimplementation group to 61% postimplementation (absolute increase, 24%; 95% CI, 11% to 37%; P < .001). Adherence improved for quality indicators for infiltration into wounds (137 of 254 patients [54%] to 50 of 70 patients [71%]; P = .009), administration distant from rabies vaccine site (180 of 254 [71%] to 58 of 70 [83%]; P = .04), and administration that avoids the buttock (168 of 254 [66%] to 58 of 70 [83%]; P = .007). No instances of sciatic nerve injury or compartment syndrome were observed. Conclusions and Relevance: In this quality improvement study, implementation of a rabies PEP bundle was associated with improved patient selection and delivery of human rabies immune globulin in EDs across a multihospital health system. Although the bundle included ED staff education and patient discharge education, the observed improvement was likely driven by clinical decision support from the rabies PEP ED order set. Future research should evaluate implementation of this clinical decision support at other health systems.