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

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<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
PART III. PROCESS AND OUTCOME MEASUREMENT The authors concluded that the hand hygiene programme was cost saving if less than 1% of the reduction in HCAIs observed was attributable to improved hand hygiene practices. An economic analysis of the “cleanyourhands” hand hygiene promotional campaign conducted in England and Wales concluded that the programme would be cost beneficial if HCAI rates were decreased by as little as 0.1%. The impact of the “cleanyourhands” campaign is the subject of a 4-year research programme which will look at the effectiveness of the various components of the multimodal approach. A quasi-experimental study in Viet Nam to assess the impact of the introduction of an alcohol- and chlorhedixine-based hand santizer for hand antisepsis on SSI rates among neurosurgical patients revealed a reduction in the infection rate by 54% and a reduction in post-operative length of stay and antimicrobial use from 8 days to 6 days (P
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