Emergency Medicine

Avoidable emergency department visits for rabies vaccination

a b s t r a c t

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 ra- bies 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 vaccina- tion 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 re- turn 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 ra- bies 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.

(C) 2022

  1. Introduction

Rabies is a world-wide neglected tropical disease that accounts for more than 59,000 human deaths per year [1]. Although rabies may disproportionally impact poor and Rural communities, prevention of rabies remains an active issue in the United States where an estimated

Abbreviations: CI, confidence interval; ED, emergency department; EHR, electronic health record; ESI, emergency severity index; HRIG, human rabies immune globulin; PEP, postexposure prophylaxis; SD, standard deviation.

* Corresponding author at: Department of Surgery, Houston Methodist Hospital, 6550 Fannin St, SM1661, Houston, TX 77030, USA.

E-mail address: [email protected] (J.T. Swan).

30,000 to 60,000 people initiate rabies postexposure prophylaxis (PEP) each year [1,2]. Appropriate rabies PEP is necessary to prevent ra- bies infection after exposure to a potentially rabid animal and consists of wound cleansing, human rabies immune globulin (HRIG), and 4 to 5 doses of rabies vaccines [3]. Patients usually receive wound manage- ment, HRIG, and the first dose of rabies vaccine during the initial healthcare visit, which commonly occurs at an emergency department (ED) in the United States. The Intramuscular injection of subsequent doses of rabies vaccine (usually days 3, 7, and 14) is not a medical emer- gency and does not require access to emergency services. If a rabies vac- cine dose is due on a weekend or holiday, it is allowable to reschedule the dose for 1 to 3 days later to a more convenient date. Therefore, pa- tients can be referred to clinics and retail pharmacies to receive


0735-6757/(C) 2022

subsequent doses of rabies vaccine. In the United States, rabies is a neglected disease due to low patient volume, lack of infrastructure for coordination of care, and high costs for rabies PEP medications. Few re- tail pharmacies, Primary care clinics, and specialty clinics routinely stock rabies vaccine due to low patient volume and high medication costs. Therefore, appropriate referral at ED discharge can be challenging as the ED physician may not be aware of which pharmacies and clinics stock and can administer rabies vaccine. When patients who are discharged from the ED have difficulty scheduling clinic appointments or encounter financial barriers to rabies vaccine access, they may inap- propriately discontinue the rabies vaccine series or return to the ED without any urgent or emergent medical conditions [4]. Failure to com- plete the rabies vaccine series may increase the risk for developing human rabies, which is almost 100% fatal once symptoms develop [2]. Additionally, this avoidable utilization of the ED diverts valuable ED re- sources from patients with more urgent conditions. While evaluating rabies PEP delivery in the ED, our team identified ED visits that appeared to be exclusively for administration of rabies vaccine [5]. No previously published study has formally evaluated the magnitude of this potential issue. Therefore, the objective of this study was to formally characterize the prevalence of avoidable ED visits for rabies vaccine only.

  1. Methods
    1. Study setting

This retrospective study was conducted across 15 EDs of a multi- hospital health system including 1 academic medical center, 6 commu- nity hospitals, and 8 freestanding emergency care centers staffed by board-certified physicians in Houston, Texas. The health system transi- tioned to a new electronic health record in 2016 and 2017. Pa- tients who received HRIG or rabies vaccine for rabies PEP from May 27, 2016 through June 30, 2018 during an ED encounter that was docu- mented in the new EHR were included. During the study period, HRIG 150 IU/mL and 300 IU/mL products (HyperRAB(R) S/D and HyperRAB(R), Grifols Therapeutics Inc., Clayton, NC, USA), human diploid cell vaccine (Imovax(R), Sanofi Pasteur Inc., Swiftwater, PA, USA), and purified chick embryo cell vaccine (RabAvert(R), GlaxoSmithKline, Research Triangle Park, NC, USA) were used at the health system. This retrospective study was approved by the health system’s institutional review board with a waiver of informed consent.

    1. Study design

All ED visits at our health system where HRIG or rabies vaccine was administered for rabies PEP during the study period were included in this analysis. The first ED visit at our health system where HRIG or rabies vaccine was administered was considered the index ED visit, and all pa- tient characteristics were presented from this point of reference. All ED visits at our health system were classified as initial or non-initial healthcare visits. We defined an initial healthcare visit as a patient’s first physical contact at any Healthcare facility (ED or non-ED visit that was internal or external to our health system) following animal expo- sure regardless of delivery of HRIG or rabies vaccine. Phone calls were not considered as physical contact. It was assumed that ED visits for ini- tial healthcare were necessary because patients were receiving their first physical assessment from a physician. Emergency department visits for non-initial healthcare were classified as necessary for the fol- lowing reasons: HRIG administration, worsening symptoms, other emergent conditions, or rabies vaccination during a natural disaster when non-ED facilities were not operating. Emergency department visits for rabies vaccination only were classified as avoidable. Potential non-mutually exclusive contributing factors (instructed to follow up in ED, unwilling or unable to coordinate follow up in community setting, and financial or insurance obstacles) for avoidable ED visits were de- rived by investigators using standardized operating procedures to

interpret non-standardized EHR documentation. Data was extracted from physician notes, nurse notes, flowsheet documentation (including skin and wound assessments), medication administration records, dis- charge prescriptions, discharge planning notes, and patient communi- cations for all ED and non-ED visits related to rabies PEP healthcare that were documented in the EHR at our health system or a health sys- tem that participated in the Epic Care Everywhere Network (Epic Sys- tems Corporation, Verona, WI, USA). Two investigators independently abstracted all study data from the EHR using REDCap data collection forms, and discrepancies between reviewers were arbitrated by the same investigators and the principal investigator [6]. Upon presentation to the ED, Triage nurses documented the patient’s acuity using the 5- level Emergency Severity Index ranging from 1 (most urgent) to 5 (least urgent) [7]. The ESI level was retrospectively assigned using available EHR documentation for one patient with missing ESI docu- mentation. Since insurance coverage and copayment may influence ac- cess to rabies vaccine, we collected information on each patient’s insurance status and provider.

    1. Analysis

Descriptive statistics of means with standard deviations for continu- ous data and frequencies with proportions for categorical data were used. The 95% confidence interval (CI) for having avoidable ED visits was calculated using the binomial test for one sample. The sequence of rabies PEP follow-up locations including ED (state 1), community set- ting (state 2), and lost to follow-up (state 3) over time were modeled using a discrete-time Markov chain to describe the probability of pa- tients transitioning between ED and Community settings for subsequent rabies vaccination. The probability transition matrix and associated standard errors were estimated using maximum likelihood estimation among a subset of patients who returned to either ED or community settings for the second rabies PEP follow-up were included in this anal- ysis. Statistical analyses were conducted in STATA version 16 (StataCorp LP, College Station, Texas) and R version 4.0.3 (The R Foundation for Sta- tistical Computing). Graphics were developed using GraphPad Prism version 8.1.1 (GraphPad Software Inc., San Diego, California).

  1. Results
    1. Patient characteristics

A total of 145 patients were included in this study, of which 138 pa- tients received the first administration of rabies vaccine or HRIG during an ED visit at our health system (Table 1). Prior to the index visit at our health system, 7 (5%) patients received at least one dose of rabies vac- cine and 2 (1%) patients received HRIG. Prior to the index ED visit at our health system, some patients received initial healthcare for the ra- bies exposure at urgent care clinics (n = 10, 7%), primary care physician offices (n = 8, 6%), EDs in our health system with no administration of HRIG or rabies vaccine (n = 4, 3%), EDs in other health systems (n = 4, 3%), healthcare facilities in another state (n = 2, 1%), or healthcare facil- ities in another country (n = 5, 3%). Twelve patients with ESI levels of 2 (n = 4) and 3 (n = 8) were admitted to hospital due to infection (n = 9), complex Wound management (n = 2), and bone fracture unrelated to animal wounds (n = 1).

    1. Patients with avoidable ED visits

Of 145 patients included in this study, 28 (19%, 95% CI = 13% to 27%) had >=1 avoidable ED visits (Fig. 1A). Avoidable ED visits occurred com- monly among patients who were >=65 years old (32%, 95% CI = 14% to 55%) (Table 2).

Table 1

Baseline characteristics.

Variables Total (n = 145)

Age in years, mean +- SD 40 +- 20

Female, n (%) 76 (52%)

Race, n (%)

Caucasian/White 116 (80%)

Black/African American 11 (8%)

Table 2

Potential determinants of avoidable ED visits (n = 145).

Variables Total, n Patients with >=1 avoidable ED visits n % 95% CI

Total 145 28 19% 13% to 27%



Immunocompromised patients, n (%)a

18 (12%)

2 (1%)

0 to 17 years




4% to 43%

18 to 64 years




10% to 26%

>=65 years




14% to 55%

Female, n (%)

Insurance type, n (%)




15% to 35%

History of rabies exposure, n (%)b 2 (1%) Animal type, n (%)

Dog 72 (50%)

Bat 37 (26%)

Cat 21 (14%)

Raccoon 9 (6%)

Otherc 6 (4%)

Animal exposure type, n (%)

Bite 108 (74%)

Close encounterd 18 (12%)

Direct contact 7 (5%)

Bite and scratch 6 (4%)

Scratch 5 (3%)

Lick 1 (1%)

Days from animal exposure to index ED visit, mean +- SD 2 +- 4 Insurance type, n (%)

Private insurance

66 (46%)


27 (19%)


21 (14%)


18 (12%)


13 (9%)

ED, emergency department; SD, standard deviation.

a Patients who were on immunosuppressive agents or had active immunosuppressive disorders.

b One patient received rabies vaccines 2 years before the observed animal exposure, and one patient received rabies vaccine 3 years before the observed animal exposure.

c Other animals included squirrel, monkey, and opossum.

d During a close encounter, the patient did not directly touch the animal (e.g., bat found in a bedroom).

e Other Insurance types included international, military, and workers compensation insurance.

Image of Fig. 1

Fig. 1. Types of ED visits. ED, emergency department.

Private insurance




10% to 30%





9% to 42%





8% to 47%





1% to 35%





5% to 54%

CI, confidence interval; ED, emergency department.

Wound suturing, n (%)b




1% to 32%

Infected wounds, n (%)c




2% to 52%

a Other insurance types included international, military, and workers compensation insurance.

b Patients who had wound sutures during the index ED visit.

c Patients who had Wound infection during the index ED visit.

    1. Identification of avoidable ED visits

A total of 203 ED visits were evaluated, representing 1 (n = 118), 2 (n = 10), 3 (n = 3), or 4 (n = 14) ED visits per patient among 145 pa- tients. Among 113 ED visits for initial healthcare, 84 (74%) visits were classified as less urgent (ESI level was 4 or 5) and 108 (96%) did not re- quire Ambulance transport (Table 3). Among 90 ED visits for non-initial healthcare, 31 (34%) were classified as necessary and 59 (66%) were classified as avoidable (Fig. 1B). The average number of avoidable ED visits observed per patient was 0.41 (95% CI = 0.25 to 0.56). For the 59 avoidable ED visits, no patients required ambulance transport, a less urgent acuity (ESI level of 4 or 5) was documented for 98% (58 of 59), and no patients were admitted to the hospital (Table 3). Although one patient with an ESI level of 3 for this avoidable ED visit presented to the ED for a second dose of rabies vaccine following a raccoon bite on the shin, the patient did not receive any wound care, imaging, or management of other urgent medical conditions during the ED visit. Common contributing factors for avoidable ED visits were that ED staff instructed the patient to return to the ED for a subsequent vaccine dose (n = 20) or the patient was unable to successfully coordinate a follow-up visit at the outpatient facility where they were referred (n

= 17) (Fig. 2). Weekend or holiday ED visits occurred for 28% (56 of 203) of all ED visits and for 22% (13 of 59) of avoidable ED visits.

    1. Chain of care

An analysis was conducted among 138 patients who initiated ra- bies PEP at our health system to evaluate chain of care between visits (Fig. 3A). A subset of 34 patients who had documentation of rabies PEP follow-up visits in our health system’s EHR were included in the Markov model. Among patients with a follow-up visit in the ED, the probability of returning to the ED for a future follow-up visit was 73% (Fig. 3B and Table S1). Patients with a follow-up visit in the com- munity setting had a 94% probability of continuing care in community setting.

  1. Discussion

This is the first study that evaluated the use of ED resources to de- liver subsequent rabies vaccines for patients receiving rabies PEP at a health system in a large, urban area in the United States. This study clas- sified each ED visit for rabies PEP as necessary or avoidable based on the

economic impact of avoidable ED vis”>Table 3

Characteristics of ED visits.

ED visits for initial healthcare (n = 113) Necessary ED visit (n = 31) Avoidable ED visit (n = 59) Total (n = 203)

Acuity, n (%)a

ESI level 4 or 5 (less urgent)

84 (74%)

23 (74%)

58 (98%)

165 (81%)

ESI level 2 or 3 (more urgent)

29 (26%)

8 (26%)

1 (2%)

38 (19%)

Means of arrival, n (%) Walk-in

108 (96%)

30 (97%)

59 (100%)

197 (97%)


5 (4%)

1 (3%)

0 (0%)

6 (3%)

ED, emergency department; ESI, emergency severity index.

a The ESI was not recorded for one patient and was retrospectively assigned based on existing EHR documentation.

need for initial assessment of wounds, delivery of HRIG, and manage- ment of emergent medical conditions. Surprisingly, 19% of patients who received rabies PEP in the ED had at least one avoidable ED visit that did not require access to emergency services and was exclusively for rabies vaccination. inappropriate use of ED resources is a worldwide dilemma that places a financial strain on patients and the healthcare system [8,9]. This study highlights systemic lack of coordination follow- ing ED discharge and barriers to accessing rabies vaccine in the United States [10]. Although patients sought preventative care in urban and suburban settings in the United States, issues are likely magnified for patients who have a low income or live in rural areas. In direct response to data from this study, future initiatives should aim to develop im- proved coordination of care programs to support access to rabies vac- cine following ED discharge [10]. Future efforts that aim to reduce avoidable ED visits should ensure that patients have access to rabies vaccine in non-ED settings as completion of an indicated rabies vaccine series is more important than avoiding ED visits.

    1. Economic impact of avoidable ED visits

It is reasonable to assume that administering a rabies vaccine during an avoidable ED visit generates excess Healthcare costs to patients and third-party payors as compared to administering the same vaccine in an outpatient clinic or retail pharmacy. Patients who started HRIG or ra- bies vaccine in an ED at our health system experienced an average of

0.41 (95% CI = 0.25 to 0.56) avoidable ED visits. The Centers for Disease

Control and Prevention estimate that 30,000 to 60,000 patients initiate rabies PEP each year in the United States [2]. If the findings from our study can be generalized broadly to the United States, we estimate that 7500 to 33,600 avoidable ED visits occur for rabies vaccination in the US each year. Future studies should characterize excessive healthcare costs associated with avoidable ED visits for rabies vaccine. public policy should look for opportunities to decrease avoidable ED visits and reinvest these financial resources to develop coordination of care programs that help patients easily obtain cost-effective access to rabies PEP.

    1. Contributing factors for avoidable ED visits

The discharge instructions during each healthcare visit for rabies PEP should include an appropriate referral plan for remaining rabies vaccine doses that are medically indicated. The most common contrib- uting factor for avoidable ED visits observed in our study was subop- timal instructions by ED physicians or nurses to return to the ED for future administrations of rabies vaccine. Therefore, interventions to prevent avoidable ED visits must optimize ED discharge planning by identifying and overcoming barriers that are faced by ED clinicians. One potential barrier for appropriate referral at ED discharge is that many retail pharmacies, primary care clinics, and infectious disease clinics are not able to provide rabies vaccinations. The second most common contributing factor for avoidable ED visits was a patient’s un- willingness or inability to coordinate the follow-up plan that was

Image of Fig. 2

Fig. 2. Contributing factors for necessary and avoidable ED visits. ED, emergency department; f/u, follow-up.

Reasons and contributing factors were not mutually exclusive. Reasons and contributing factors were adjudicated by investigators through review of EHR documentation.

?Patients sought care in outpatient facilities which could not administer rabies vaccines.

Image of Fig. 3

Fig. 3. Chain of care and probability of having avoidable ED visits.

ED, emergency department; HRIG, human rabies immune globulin; PEP, postexposure prophylaxis.

?This included 3 patients admitted to the hospital from the ED which was considered as one continuous visit. These patients received a 2nd vaccine dose during the hospital admission and were then lost to follow-up after discharge from the hospital.

+This included 3 ED visits where rabies vaccine was not administered. One patient did not receive rabies vaccine during follow-up visit 1 as the ED physician determined that rabies vaccine

was no longer indicated. Two patients only received HRIG during follow-up visit 1.

?Discrete states of the Markov chain model for the follow-up location were ED (state 1), community setting (state 2), and lost to follow-up (state 3). This analysis included 34 patients.

provided at ED discharge. We did not find compelling evidence that receiving a rabies vaccination on a holiday or weekend was a common contributing factor to avoidable ED visits. Financial or insurance obsta- cles or referral to a facility that could not provide rabies vaccine were also documented for 6 patients; however, documentation of this infor- mation is not standardized and may be underreported in the EHR. Due to limitations in EHR documentation, future research should survey patients directly to further characterize contributing factors for avoid- able ED visits for rabies vaccine.

    1. Chain of care

Of 138 patients who started rabies PEP in an ED at our health sys- tem, the majority (75%) of patients only had one healthcare visit doc- umented in our EHR. These patients were lost to follow-up, and we

could not determine if subsequent doses of rabies vaccine were missed or were given at facilities external to our health system (in- cluding retail pharmacies). Shi et al., conducted a phone survey study in Pennsylvania and reported that 83% (145 of 174) of patients who started rabies vaccine in the ED completed the rabies vaccine se- ries of four doses [11]. Therefore, it is possible that many patients who were lost to follow-up in our study received subsequent doses of ra- bies vaccine at external facilities. Among 34 patients with documenta- tion of at least 2 rabies vaccine doses in our EHR, we used a Markov chain model to characterize transitions between ED and community setting for subsequent vaccine doses. This study showed that history of a previous avoidable ED visit was a strong predictor of having a fu- ture avoidable ED visit. This suggests that rapid identification of pa- tients with an avoidable ED visit and appropriate intervention can prevent future avoidable ED visits.

    1. Future direction

Although some urgent care clinics, infectious disease/travel medi- cine clinics, and retail pharmacies routinely carry and can administer ra- bies vaccine in the Houston area, most physician clinics and retail pharmacies do not carry rabies vaccine due to low patient volumes. Sys- temic issues with the US healthcare system have resulted in limited numbers of referral sites that can administer rabies vaccine and no stan- dardized infrastructure to communicate these referral sites to ED physi- cians which results in avoidable ED visits. Although the American College of Emergency Physicians recommends that EDs build referral systems that connect patients with public health entities, urgent cares, clinics, and pharmacies for vaccination, these services may not be fully developed for rare diseases like rabies [12]. Development of care man- agement services for ED patients can facilitate scheduling of follow-up visits with primary care or specialty clinics, connect patients with com- munity resources, and reduce non-emergent ED utilization [13-16]. The University of Kentucky HealthCare created a system to refer patients to urgent care and Prisma Health Midlands refer to an outpatient phar- macy within the health system for subsequent doses of rabies vaccine [10]. Future research is needed to develop and evaluate the impact of ra- bies vaccine care management programs and services that facilitate ac- cess to rabies vaccine following ED discharge.

    1. Limitations

The major limitation of this study was the retrospective design which used secondary data that was stored in the EHR for the primary purpose of supporting patient care and is subject to all inherent limita- tions of using this type of data such as non-standardized documentation by clinical staff and some missing data. This study was not able to cap- ture rabies vaccination data from community pharmacies and non- network clinics, and investigators were only able to confirm administra- tion of all 4 doses of rabies vaccination for 16% of patients. Fortunately, no cases of human rabies were reported by the state of Texas to the CDC during the 2016 to 2018 study period [2]. This study was only able to describe avoidable ED visit for rabies vaccine that occurred in our health system, and it is possible that some patients in this study had avoidable ED visits for rabies vaccine at EDs external to our health system. Administration of HRIG was the most common reason that ED visits for non-initial healthcare were classified as necessary. If patients can reliably obtain access to HRIG outside of the ED, additional ED visits in our study could be classified as avoidable. Contributing factors for avoidable ED visits were inferred from EHR documentation and were likely underreported.

  1. Conclusions

One out of every 5 patients who received rabies PEP in the ED had avoidable ED visits for subsequent rabies vaccination, diverting valuable ED resources from patients with more urgent conditions and increasing Health care costs. Most (66%) ED visits for non-initial healthcare were avoidable from a broad healthcare delivery and system perspective. Healthcare leaders in emergency medicine should look for opportuni- ties to decrease avoidable ED visits and reinvest recuperated financial resources to develop coordination of care programs that help patients easily obtain cost-effective access to rabies PEP. Future programs are needed to coordinate access to rabies vaccine in non-ED settings to pre- vent avoidable ED visits for rabies vaccination.

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2022.02.007.

Disclosure of funding

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Prior presentations

A scientific abstract containing preliminary results was presented at the Virtual ISPOR 2020, in May 2020 (published Value in Health 2020;23:S181).

Author contributions

TI, FY, and JTS wrote the protocol. TI, FY, ER, and ATT collected study data. TI managed the study database, conducted the analysis, and wrote the first draft of the manuscript. JTS supervised the study team. RBS, PRB, NAN, and DE provided expert perspective on patient care and workflow in emergency department. JSB provided expert perspective on data analysis. All authors reviewed and approved the final version of the manuscript.

Credit authorship contribution statement

Tomona Iso: Writing – review & editing, Writing – original draft, Visu- alization, Validation, Software, Resources, Project administration, Method- ology, Investigation, Formal analysis, Data curation. Fangzheng Yuan: Writing – review & editing, Visualization, Validation, Resources, Investiga- tion, Data curation. Elsie Rizk: Writing – review & editing, Resources, Investigation. Anh Thu Tran: Writing – review & editing, Resources, Inves- tigation. R. Benjamin Saldana: Writing – review & editing, Resources, In- vestigation. Prasanth R. Boyareddigari: Writing – review & editing, Resources, Investigation. Ngoc-anh A. Nguyen: Writing – review & editing, Resources, Investigation. Daniela Espino: Writing – review & editing, Re- sources, Investigation. Julia S. Benoit: Writing – review & editing, Formal analysis. Joshua T. Swan: Writing – review & editing, Visualization, Validation, Supervision, Software, Resources, Project administration, Meth- odology, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of Competing Interest

The authors declare the following financial interests/personal rela- tionships which may be considered as potential competing interests: JTS received an advisory board stipend that was paid to his employer by Kedrion Biopharma Inc. and investigator-initiated research funding that was paid to his employer by Grifols Shared Services North America, Inc. and Kedrion Biopharma Inc. (both are manufacturers of ra- bies immune globulin). TI, FY, ER, ATT, RBS, PRB, NAN, DE, and JSB report no conflict of interest.




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