Epicenter V: Harvard Pilgrim Health Care Institute Center for Excellence in HAI Surveillance and Prevention

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Abstract Epicenter V: Harvard Pilgrim Health Care Institute Center for Excellence in HAI Surveillance and Prevention: Core Projects This Epicenter will pursue six aims to develop essential information to guide improved management of sepsis, non-ventilator hospital acquired pneumonia, and prevention of C. difficile infection among hospital inpatients. The sepsis work will be grounded in analyses of electronic health record data from 300 hospitals drawn from HCA Healthcare and Cerner’s HealthFacts database, together covering the years 2013 through 2019, and involving 1 million sepsis admissions. These studies will use advanced causal inference methods to address three major questions with direct relevance both to management of sepsis and to national mandates and reimbursement policies. These questions are: 1) How does severity of illness at presentation affect the relationship between time-to-antibiotic and survival among patients with bloodstream infections? 2) How common and serious are adverse effects of short course empiric antibiotic therapy among patients with suspected sepsis who prove to have non-infectious conditions? 3) What are the consequences of failure to de- escalate empiric antibiotics prescribed for suspected sepsis after infection is ruled out? The first non-ventilator hospital acquired pneumonia (NV-HAP) aim will address a critical unknown about this common and frequently fatal condition – to what extent are NV-HAP associated deaths preventable? This assessment will use previously validated methods by which expert clinicians review full text medical records from both teaching and community hospitals to determine the cause of death and to determine its relationship to NV-HAP. These findings will inform the urgency of implementing national surveillance and reporting of NV-HAP occurrence, and of designing and testing mitigation strategies. The second NV-HAP aim will design and test a pharmacist led opt-out protocol for discontinuing antibiotics for the 20% of inpatients diagnosed with NV-HAP who have normal clinical signs. This randomized trial will be powered to assess the impact on antibiotic utilization and lay the groundwork for a later definitive trial of the impact on patient outcomes. The final aim will address methods for preventing hospital-onset C. difficile infection amongst high risk patients. We will identify patients colonized with C. difficile via PCR testing of VRE surveillance swabs obtained on admission. Colonized patients in the intervention period will receive a prevention bundle including antibiotic and antacid stewardship as well as consideration of prophylactic probiotics and oral vancomycin.