Decreasing Surgical Site Infections in Mohs Surgery

Project Team Members Stan Taylor, MD UTSW Dermatology Stacey Clark, RN, MBA UTSW Ambulatory Administration Anju Varghese, MPH, CIC UTSW Ambulatory Infection Control John Morris UTSW Organization Development

Background The Dermatology-Surgical Oncology (DSO) clinic performs over 200 procedures each month with the majority being Mohs surgeries. All patients were receiving oral post-operative anti-Staphylococcal antibiotic prophylaxis. Was this overuse of antibiotics? An increase in the SSI rate was noted in May 2010. Could we review our processes and identify a bundle of interventions that would reduce the SSI rate and develop safer care?

Aim Statement The baseline (Dec 2009-Jun 2010) SSI rate was 1.18 infections per 100 procedures. By instituting a standardized bundle of patient care interventions on 6/14/10, our goal was to reduce SSIs in Mohs surgical patients by 50% over the subsequent 6 months.

Process Analysis

Mohs Surgery Flowchart Referral and path report received and reviewed pt sched, CSA explains procedure, mails paperwork confirmation call to pt prior to appt patient arrives, registered; room is already set up take pt to room, take pictures consents signed, mark the site fellow preps site and numbs area nurse preps site -process varies by nurse 1st stage, cautery w/smoke evac wound dressed – process varies by nurse Mohs tray is covered between stages. Pt sent to waiting room. Average wait 1 hr. Room is cleaned before next patient Possible addl stages: same room, same equipment Repair: open sterile tray, prep room Prep and drape pt d/c instructions, pt goes home Postop visit in 1 wk, sooner if necessary

Mohs Surgery Fishbone

Interventions 9/16/2018

Infection Control Bundle (implemented 6/14/10) Prophylactic antibiotics restricted 3 areas of focus: Better patient skin prep before initial and subsequent stages Better handling of equipment and patient care supplies Improve patient education 9/16/2018

Standardized Indications for Post-Operative Prophylactic Antibiotics Immunosuppressed patients Areas that are outside the head and neck region Multiple stage cases (> 4 stages) Defects > 5 cm in diameter Full thickness skin grafts Multiple site surgery Diabetes Mellitus Delayed Closures (> 1 week) on the ear, groin, periocular or extremity regions 9/16/2018

Staff Surveys Checklist to assess implementation of bundle Yes No For staff Did the surgical team perform an initial 3min hand scrub? Was the Mohs tray only opened right before the patient was roomed? Was the patient asked to clean his hands and surgery site prior to start? Was the initial skin prep appropriate? (covered large enough area, repeated twice) Was the skin prepped before each subsequent stage? (wound rinsed, antiseptic applied) Was a larger dressing used after each stage (e.g. Telfa was not cut)? Was the Mohs tray covered appropriately when not in use? Were patient and family given written and verbal post-op instructions? Did we document that patient verbalized understanding? 9/16/2018

Patient Surveys Checklist to assess implementation of bundle Yes No For Patients Did you bathe or shower during the 24 hours prior to your surgery? After your surgery, did you receive instructions about caring for your wound? Did you receive information about hand hygiene and preventing infections? Did you understand these instructions? Did you clean your hands before and after caring for your wound at home? Did you know how to recognize a possible wound infection? Did you know how to contact the clinic if you had a problem with your wound? 9/16/2018

New Patient Handout

Results

Patient and Staff checklists Patient checklists Improvement in all areas in July Decrease in all areas in Aug except “hand hygiene at home” which remained high Very low response rate (3%-10%) Staff checklists Showed improvement in all areas Response rates varied (Jun 48%, Jul 74%, Aug 50%) Discontinued in August

Weekly SSI rates Dec 2009 – Dec 2010 As of 12/31/10, there was a 48% decrease in the post-intervention SSI rate compared to the baseline rate. Bundle initiated 6/14

Additional Results Eliminated the use of oral antibiotics in 75% of our patients. Estimated cost savings of $5500/year. At least 30 days without a SSI: Once during baseline period Twice during 6mos post-intervention 3 times during 9mos post-intervention Staff is often resistant to change due to fears that process changes will decrease efficiency, but this was not the case. Staff motivation waned quickly! Difficult to maintain enthusiasm and attention to detail.

Conclusions

Interventions were effective SSI rate decreased by 48% during the 6mos post-intervention and by 60% during 9mos post-intervention. After our intervention, clinic had longer periods without a SSI. Prophylactic antibiotics alone do not prevent SSIs. Infection prevention measures are vital.

Sustaining improvements We continue to monitor for SSIs We continue to adhere to the bundle Regular feedback is provided to clinic staff Clinic performs root cause analysis of each SSI Surveillance data (e.g. # days since last SSI) is posted to motivate staff

Sustaining improvements Since this project, SSI rate continues to fluctuate Overall rate is lower than pre-intervention 2011 YTD, 9 gram positives and 11 gram negatives 2010, 24 gram positives and 9 gram negatives. The decrease in gram positives most significantly implies that we are performing better skin preparation on the patient. As of 10/25/11, 57 days have passed since the last infection which is the 2nd longest time span between SSIs. The record “days between infections” was 86 days from 1/1/11-4/7/11.