WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
in 1.0–1.2 litre bags for use in wall-mounted dispensers are
the least expensive; pump bottles and small pocket-sized
bottles are more expensive; and foam products that come
in pressurized cans are the most expensive. Presumably,
a locally-produced solution composed of only ethanol or
isopropanol plus 1% or 2% glycerol would be less expensive
than commercially produced formulations. Boyce estimated
that a 450-bed community teaching hospital in the USA spent
US$ 22 000 (US$ 0.72 per patient-day) on 2% chlorhexidinecontaining
preparations, plain soap, and an alcohol-based hand
rinse. 1053 When hand hygiene supplies for clinics and non-patient
care areas were included, the total annual budget for soaps
and hand antiseptic agents was US$ 30 000 (about US$ 1 per
patient-day).
Annual hand hygiene product budgets at other institutions vary
considerably because of differences in usage patterns and
varying product prices. Countries/states/regions/localities with
centralized purchasing can achieve economies on a scale that
can result in considerable cost reduction of products. A recent
cost comparison of surgical scrubbing with an antimicrobial
soap versus brushless scrubbing with an alcohol-based
handrub revealed that costs and time required for pre-operative
scrubbing were less with the alcohol-based product. 328 In a trial
conducted in two ICUs, Larson and colleagues 329 found that the
cost of using an alcohol-based handrub was half that of using
an antimicrobial soap for handwashing (US$ 0.025 vs US$
0.05 per application, respectively). In another study conducted
in two neonatal ICUs, investigators looked at the costs of a
traditional handwashing regimen using soap, use of an alcoholbased
handrub supplemented by a non-antimicrobial soap, use
of hand lotion, and nursing time required for hand hygiene. 646
Although product costs were higher when the alcohol-based
handrub was used, the overall cost of hand hygiene was lower
with the handrub because it required less nursing time.
3.5 Typical cost-savings from hand hygiene
promotion programmes
To assess the cost savings of hand hygiene promotion
programmes, it is necessary to consider the potential savings
that can be achieved by reducing the incidence of HCAIs. One
of the easiest ways to assess the cost savings is to estimate the
excess hospital costs associated with the excess patient days
caused by HCAIs. In a recent study by Stone and colleagues,
costs of catheter-related bloodstream infection (CR-BSI),
surgical site infection (SSI), ventilator-associated pneumonia
(VAP), and hip SSIs were estimated and found to be a minimum
of US$ 5500 per episode. The authors further reported that
CR-BSI caused by MRSA may cost as much as US$ 38 000
per episode. 1054 Table III.3.1 provides a summary of the costs
of the four most common HCAIs based on a systematic review
of literature published by Stone and colleagues for periods
1990–2000 and 2001–2004. 15,1055
In addition to the costs reported above, there are several hidden
costs that are not included in the calculation of these figures.
These costs could instead be referred to as lost “opportunities
for saving”. Stone and colleagues provide several examples.
An unscheduled revisit to the operating room for incision and
drainage after an SSI can limit the number of procedures that
can be performed in a day. Hold-ups often cause delays and
postponement of scheduled procedures. Another example of a
hidden cost includes the dissatisfaction of the patient and the
referring doctor. Research suggests that dissatisfied customers
often have the tendency to tell more people about the
deficiencies in their care. Hence, the loss of existing customers
(patients) means higher replacement costs associated with
attracting and receiving new patients. These include costs for
marketing and registering new patients into the medical records
system and the costs of countering any negative publicity and
building renewed trust.
Thus, it is not surprising that the excess hospital costs
associated with only four or five HCAIs of average severity may
equal the entire annual budget for hand hygiene products used
in inpatient care areas. Just one severe SSI, lower respiratory
infection, or BSI may cost the hospital more than the entire
annual budget for antiseptic agents used for hand hygiene. 1053
For example, in a study conducted in a Russian neonatal ICU,
the authors estimated that the excess cost of one health careassociated
BSI (US$ 1100) would cover 3265 patient-days of
hand antiseptic use (US$ 0.34 per patient-day). 687 The authors
estimated that the alcohol-based handrub would be cost saving
if its use prevented approximately 3.5 BSIs per year or 8.5
pneumonias per year. In another study, it was estimated that
cost savings achieved by reducing the incidence of C. difficileassociated
disease and MRSA infections far exceeded the
additional cost of using an alcohol-based handrub. 429
Several studies provided some quantitative estimates of the
cost savings from hand hygiene promotion programmes. 60,181
Webster and colleagues 181 reported a cost saving of
approximately US$ 17 000 resulting from the reduced use
of vancomycin following the observed decrease in MRSA
incidence over a 7-month period. Similarly, MacDonald and
colleagues reported that the use of an alcohol-based hand gel
combined with education sessions and performance feedback
to HCWs reduced the incidence of MRSA infections and
expenditures for teicoplanin (used to treat such infections). 489
For every UK£ 1 spent on alcohol-based gel, UK£ 9–20 were
saved on teicoplanin expenditure.
Including both direct costs associated with the intervention
(increased use of handrub solution, poster reproduction, and
implementation) and indirect costs associated with HCW time,
Pittet and colleagues 60 estimated the costs of the programme
to be less than US$ 57 000 per year for a 2600-bed hospital,
an average of US$ 1.42 per patient admitted. Supplementary
costs associated with the increased use of alcohol-based
handrub solution averaged US$ 6.07 per 100 patient-days.
Based on conservative estimates of US$ 100 saved per
infection averted, and assuming that only 25% of the observed
reduction in the infection rate has been associated with
improved hand hygiene practice, the programme was largely
cost effective. A subsequent follow-up study performed in the
same institution determined the direct costs of the alcoholbased
handrub used, other direct costs, indirect costs for
hand hygiene promotion, and the annual prevalence of HCAI
for 1994–2001. 490 Total costs for the hand hygiene programme
averaged Swiss francs (CHF) 131 988 between 1995 and
2001, or about CHF 3.29 per admission. The prevalence of
HCAI decreased from 16.9 per 100 admissions in 1994 to
9.5 per 100 admissions in 2001. Total costs of HCAIs were
estimated to be CHF 132.6 million for the entire study period.
170