Decreasing Surgical Site Infections in Mohs Surgery

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

7. Mohs Surgery Fishbone

8. Interventions

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

10. Standardized Indications for Post-OperativeProphylactic 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

11. Staff SurveysChecklist to assess implementation of bundle

12. Patient SurveysChecklist to assess implementation of bundle

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.