Improving Adherence to Rabies PEP Guideline Recommendations

BACKGROUND: Rabies infection can occur in humans when key elements of the rabies PEP regimens are omitted or incorrectly administered. The CDC Advisory Committee on Immunization Practices (ACIP) recommends that patients who are exposed to rabies virus should receive prompt and thorough wound cleansing followed by administration of human rabies IG and rabies vaccine. Previous research identified three opportunities to improve adherence to CDC guideline recommendations for rabies PEP: (1) infiltration of rabies IG into and around the wounds, if anatomically feasible, (2) administration of rabies IG at an anatomical site distant from rabies vaccine administration, and (3) avoiding administration of rabies IG into the buttock.

STUDY DESIGN: This quasi-experimental, quality improvement study evaluates adherence to 6 quality indicators, which are based on CDC guideline recommendations, for patient selection and delivery of rabies IG before and after implementation of the rabies PEP quality improvement bundle. The quality improvement bundle includes EHR enhancements, ED staff education, and patient education. Patients who receive at least one dose of rabies IG or rabies vaccine at a study site during the study period will be included in this study. The historical control group includes patients treated prior to bundle implementation. The post-implementation group includes patients treated within 12 months following bundle implementation. The primary outcome is full adherence to all 6 quality indicators for rabies IG selection and delivery.

• Rabies PEP quality improvement bundle (Other): The rabies PEP quality improvement bundle consists of (1) electronic health record enhancements to support rabies PEP treatment selection, administration, and discharge process; (2) education to ED staff on rabies PEP; and (3) education to patients on rabies PEP and follow-up care.

Primary outcomes

• Full adherence to 6 quality indicators for rabies immune globulin patient selection and delivery [1 day; during the patient's first medical encounter at a study site for rabies PEP]: The proportion of patients who achieve full adherence to a composite of all 6 quality indicators for rabies IG patient selection and delivery: (1) appropriate patient selection, (2) appropriate dose, (3) appropriate timing, (4) administration into and around the wound if anatomically feasible, (5) administration distant from rabies vaccine, and (6) administration that avoids the buttock (unless the wound is near the buttock) among patients who received rabies PEP.

Secondary outcomes

• Adherence to each of the 6 quality indicators for rabies immune globulin patient selection and delivery [1 day; during the patient's first medical encounter at a study site for rabies PEP]: The proportion of patients who achieve adherence to each of the 6 quality indicators for rabies IG patient selection and delivery.
• Volume of rabies immune globulin administered into or around wounds [1 day; during the patient's first medical encounter at a study site where rabies IG is administered]: The mean percent of the total volume of rabies IG administered into or around wounds, if anatomically feasible.
• Clear documentation of rabies immune globulin administration site [1 day; during the patient's first medical encounter at a study site where rabies IG is administered]: The proportion of patients with clear EHR documentation of rabies IG administration sites
• Incidence of compartment syndrome [For 7 days following rabies IG administration]: The incidence of compartment syndrome at a rabies IG infiltration site that was documented in the EHR within 7 days of rabies IG administration
• Incidence of sciatic nerve injury [For 21 days following rabies IG administration]: The incidence of sciatic nerve injury that was documented in the EHR within 21 days of rabies IG administration among patients who receive rabies IG into the buttock

Sex: All

Inclusion Criteria:

• Receive at least one dose of rabies IG or rabies vaccine at a study site during the study period

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• Joshua Swan, PharmD, MPH, Principal investigator, Houston Methodist Health System