Rabies post-exposure prophylaxis in the emergency department.

STUDY OBJECTIVES: Rabies is a zoonotic single-stranded RNA lyssavirus that can cause acute infections of the central nervous system (CNS) including encephalomyelitis, encephalitis, and meningoencephalitis that is progressively fatal. Rabies is more common in developing countries, but approximately 23,000 people in the United States (US) are estimated to have been exposed or to have received post exposure prophylaxis (PEP) yearly. Nebraska Medicine follows the Advisory Committee on Immunization Practices (ACIP) guidelines for the vaccination series, as well as the 20 units/kg administration of immunoglobulin (RIG). Nebraska Medicine Medical Center (NMC) and Bellevue Medical Center (BMC) treat the scheduling of the complete rabies vaccine series differently. At both campuses, patients receive their immunoglobulin and first vaccine in the Emergency Department (ED). At NMC, patients are scheduled to receive the remainder of their vaccination series at the outpatient infusion center by the ED pharmacist. At BMC, the subsequent vaccinations are given as "Nurse Only" return visits to the ED. The objective of this study was to compare patient compliance of two different processes for follow-up rabies vaccine series completion. This project's primary aim was to determine the rate of patient compliance for follow up rabies vaccine doses. The secondary aims of this project were to determine if there was a difference in patient follow-up compliance between the two campuses, patient specific factors that impact compliance, and potential cost savings if a dose rounding protocol for RIG was utilized. METHODS: This retrospective chart review was completed as a quality improvement project. Data from patients who had received either rabies immunoglobulin and/or a rabies vaccine, were >18 years of age, and were not admitted were collected for a 3-year period from July 1, 2019, to June 30, 2022. Data were abstracted from the patient's EMR (electronic medical records) using a SQL (Structured query language) query of pre-identified data elements. When unable to abstract with SQL query, data elements were manually abstracted. All data abstracted was collated and descriptive analysis performed. RESULTS: A total of 723 individual encounters were identified during the study period. After combining rabies series for each individual patient, 173 unique patients remained. After exclusions were applied, 143 patients were included: 104 patients from NMC, and 39 from BMC. For the primary outcome, appropriate completion between the two campuses was 78.3%. When comparing the two campuses, completion rates were higher at NMC (82% vs. 69%), although not statistically significant (p = 0.12). Appropriate completion of vaccine series was statistically significant for both payor and exposure type. Application of a dose rounding policy with those >45 kg, rounding to the nearest vial, as well as rounding down if at the midpoint interval, 56 fewer vials would have been used between the two campuses. This would have resulted in a potential cost savings of $57,928.64 over the study period.

Assessment of the Relationship between Body Mass Index and Incidence of Venous Thromboembolism in Hospitalized Overweight and Obese Patients.

STUDY OBJECTIVE: To assess whether a positive linear association exists between body mass index (BMI) and incidence of venous thromboembolism (VTE) in overweight and obese hospitalized patients. DESIGN: Single-center retrospective observational cohort study. SETTING: Large academic tertiary care medical center. PATIENTS: A total of 1452 adults hospitalized between January 1, 2013, and December 31, 2014, who weighed more than 100 kg and had a BMI of 25 kg/m2 or greater on admission, and received heparin subcutaneously for VTE prophylaxis. Patients were categorized into four subgroups based on World Health Organization BMI classification: overweight (141 patients), obese class I (305 patients), obese class II (324 patients), and obese class III (682 patients). MEASUREMENTS AND MAIN RESULTS: The primary outcome was occurrence of VTE in each subgroup; all-cause mortality and length of hospital stay were secondary outcomes. A linear trend test did not show an association between occurrence of VTE and BMI of 25 kg/m2 or greater. VTE occurred in 7 (5%) of 141 patients in the overweight group, 5 (2%) of 305 in the obese class I group, 8 (3%) of 324 in the class II group, and 18 (3%) of 682 in the class III group (p=0.573). In addition, no linear association was noted between all-cause mortality or length of hospital stay and BMI of 25 kg/m2 or greater. Overall mortality was 10% (146/1452 patients). Ten deaths (7%) occurred in the overweight group, 45 (15%) in the obese class I group, 38 (12%) in the obese class II group, and 53 (8%) in the obese class III group (p=0.067). The median length of hospital stay was 5 days (interquartile range 3-9, p=0.122) for all patients. CONCLUSION: In overweight and obese hospitalized patients who weighed more than 100 kg and had a BMI of 25 kg/m2 or greater, the incidence of VTE did not increase incrementally with increasing severity of obesity.