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
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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 antiStaphylococcal 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?
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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.
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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
nurse preps site
-process varies
by nurse
fellow preps site and numbs area
consents signed, mark the site
take pt to room, take pictures
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.
Repair:
Prep and drape pt
wound dressed
– process varies
by nurse
open sterile tray,
prep room
d/c instructions, pt goes home
Possible addl stages: same
room, same equipment
Room is cleaned
before next patient
Postop visit in 1 wk, sooner if
necessary
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6/30/2016
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Prophylactic antibiotics restricted
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3 areas of focus:
1.
2.
3.
6/30/2016
Better patient skin prep before initial and subsequent
stages
Better handling of equipment and patient care
supplies
Improve patient education
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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
6/30/2016
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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?
6/30/2016
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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?
6/30/2016
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Patient checklists
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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

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6
As of 12/31/10, there was
a 48% decrease in the
post-intervention SSI rate
compared to the baseline
rate.
Baseline rate (1.18)
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Post-intervention rate (0.61)
Rate (inf/100 procs)
4
3
2
1
0
Bundle
initiated
6/14
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Eliminated the use of oral antibiotics in 75% of our patients.
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Estimated cost savings of $5500/year.
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At least 30 days without a SSI:
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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.
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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.
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We continue to monitor for SSIs
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We continue to adhere to the bundle
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Regular feedback is provided to clinic staff
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Clinic performs root cause analysis of each SSI
Surveillance data (e.g. # days since last SSI) is
posted to motivate staff
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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
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that we are performing better skin preparation on the
patient.
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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.
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