1. Decreasing Surgical Site Infections in Mohs Surgery

2. 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

3. 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?

4. 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.

5. Process Analysis

6. 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

7. Mohs Surgery Fishbone

8. Interventions
9/16/2018

9. 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

10. 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

11. 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

12. 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

13. New Patient Handout

14. Results

15. 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

16. 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

17. 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.

18. Conclusions

19. 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.

20. 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

21. 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.