Evaluation of Updates to the Rabies Post-Exposure Prophylaxis Order Set R. Tye Fobbs, Rachael Weingarten, Rachel Rumbarger Cone Health at Moses Cone Hospital – Greensboro, NC Background: Rabies is a vaccine-preventable zoonotic viral disease affecting the central nervous system. The World Health Organization (WHO) recommends giving human rabies immune globulin (HRIG) to patients exposed to rabies if they have broken or punctured skin, or if their mucous membranes were contaminated with saliva from a mammal confirmed to have rabies or if the animal is not up to date on rabies vaccinations or the animal is unavailable for quarantine and observation. In the last 10 years, the utilization of rabies immunoglobulin and vaccinations has more than doubled in Cone Health emergency departments. There is no attributable cause to this increase in vaccination across our health systems. Inappropriate use of rabies post-exposure prophylaxis results in unnecessary costs and medical risks. A recent medication use evaluation explored the use of HRIG and rabies vaccines at Cone Health. Results showed that rabies post-exposure prophylaxis use in the emergency departments was not in accordance with WHO guidelines approximately 31% of the time. In May 2025, Cone Health introduced a rabies post-exposure prophylaxis order set to help guide providers in assessing the need for post-exposure prophylaxis for individual patients who meet criteria as well as providing a dose rounding protocol to decrease waste. This study aims to evaluate the implementation of the new rabies post-exposure prophylaxis order set in relation to the recommended WHO guidelines. Methods: This was an IRB-reviewed, determined exempt retrospective, pre-post comparator study of patients who received human rabies immune globulin (HRIG) in Cone Health emergency departments. Data was collected between January to June 2024 for the pre-intervention group and June to December 2025 for the post-intervention group. Patients were excluded if they received immune globulin at an urgent care center, did not meet inclusion criteria for dose rounding or weighed less than 37.5 kg. The primary outcome was appropriate use of HRIG. Secondary outcomes included amount of HRIG given, amount that would have been given based on weight-based dosing, amount of waste saved, cost savings incurred, number of patients that received < 90% or > 110% of their weight-based dose, and re-presentation within 30 days for a suspected adverse reaction to HRIG. Results: A total of 170 patients were screened with 70 patients in the pre-protocol group and 100 patients in the post-protocol group. The post protocol group was associated with a higher proportion of appropriate administration of HRIG when compared to the pre-protocol group [90 (90%) vs. 48 (68.5%); p = 0.0005]. There were no patients who represented within 30 days for a suspected adverse reaction to HRIG. Conclusions: Implementation of a rabies post-exposure prophylaxis order set resulted in increased compliance with administration of HRIG per WHO guidelines. Dose rounding did not result in representation within 30 days for a suspected adverse reaction to HRIG and decreased overall waste. These findings suggest that having an established order set and dose rounding protocol increases compliance with WHO guidelines while decreasing waste.
