Antiseptic Technology: Access, Affordability, and Acceptance - Statistical Data Included

Emerging Infectious Diseases, March, 2001 by John M. Boyce

Factors other than antimicrobial activity of soaps and antiseptic agents used for hand hygiene by health personnel play a role in compliance with recommendations. Hand hygiene products differ considerably in acceptance by hospital personnel. If switching from a nonmedicated soap to an antiseptic agent or increased use of an existing antiseptic agent for hand hygiene prevented a few more infections per year, additional expenditures for antiseptic agents would be offset by cost savings.

Although the antimicrobial activity of preparations used by health-care workers for hand hygiene (soap and water or waterless antiseptic agents) is an important aspect of such preparations (1,2), other factors that influence the frequency of use of hand hygiene products by personnel are important.

Access

The accessibility of sinks or other facilities may be an important factor, since nurses and other health-care personnel are expected to wash their hands frequently. Nurses wash their hands an average of 13 to 30 times each day, with as many as 44 times reported (Table 1) (3-5). In an observational study in an intensive care unit (ICU), nurses needed an average of 62 seconds to walk to a sink, wash and dry their hands, and return to the patient's bed (6). If nurses wash their hands for 10 seconds and 12 nurses work in an ICU, handwashing would require 16 hours of nursing time per shift (assuming 100% compliance with recommended handwashing practices). If nurses obtain an alcohol hand disinfectant from a bedside dispenser and 15 seconds is required for drying, 100% compliance would require 4 hours of nursing time per shift. Making a rapidly effective waterless antiseptic agent accessible at each patient's bedside should make it easier for nurses with heavy workloads to comply with recommended hand hygiene practices.

Table 1. Frequency of handwashing per shift by health-care workers

Author          Average/shift    Range

Ojajarvi (3)        20-30        11-44
Larson (4)          16-25        <8-25+
Boyce (5)           13-15         5-27

Few investigators have studied the relationship between access to sinks and handwashing frequency among healthcare workers. Preston and colleagues (7) recorded personnel compliance with recommended handwashing in an open ICU with six beds and two sinks. After the ICU was converted into an isolation unit with 16 beds and 15 sinks (a sink for nearly every bed), the crude rate of compliance improved from 16% to 30%.

In an observational study in two ICUs, frequency of handwashing by health-care workers after contact with patients or their environment was recorded (8). In the medical ICU, where the sink:bed ratio was 1:1, personnel complied with recommended handwashing measures 76% of the time. In the surgical ICU, where the sink:bed ratio was 1:4, compliance decreased to 51%, indicating that improved access to handwashing facilities increases handwashing compliance. However, differences in handwashing compliance on medical and surgical services may be related to factors such as the number of opportunities for handwashing and attitudes of personnel toward hand hygiene (9).

In a study of the impact of sink location on incidence of nosocomial infections (10), patients whose beds were located next to a sink had a 26% reduction in risk for infection compared with those whose beds were located farther away from a sink. In addition to placing sinks near patient beds whenever possible, hospitals should ensure that medical equipment adjacent to the patients' beds (e.g., ventilators or intravenous pumps) does not obstruct access to sinks. Physical barriers that restrict access to sinks may discourage personnel from washing their hands.

Automated handwashing machines have been tested, usually for improving the quality or the frequency of handwashing (11,12). Health-care personnel used these automated sinks infrequently, and they do not appear to be a useful solution to improving hand hygiene.

Other investigators observed health-care worker compliance with recommended hand hygiene practices in a medical ICU unit during three periods (13). During the baseline period, hands were washed with soap and water. Then, an alcohol-based hand disinfectant was made available, with one alcohol dispenser for every four beds. In the third period, additional dispensers were added so that there was one alcohol dispenser for each bed. During the baseline period, 25% of health-care workers washed their hands when recommended. Hand hygiene compliance improved to 41% when one alcohol dispenser was made available for every four beds and to 48% when a dispenser was placed next to every bed. This study also suggests that better access to hand hygiene facilities results in improved compliance.

Cost

Few data are available regarding the cost of antiseptic agents used for hand hygiene. In 1999, a 450-bed community-teaching hospital spent $22,000 on 2% chlorhexidine-containing preparations, plain soap, and alcohol hand rinse, for a cost of $0.72 per patient per day (Figure 1). If hand hygiene supplies for clinics and non-patient care areas are included, the total annual budget for soaps and hand disinfectants was $30,000, or approximately $1 per patient per day. Because of different use patterns and varying product prices, annual hand hygiene budgets at other institutions could vary considerably. The relative cost per liter was calculated for the products available through the hospital's buying group purchase contract (Table 2). The 2% chlorhexidine gluconate detergent was 1.7 times as expensive as the nonmedicated soap, and the alcohol-based hand gel was twice as expensive. Expenditures for soap or waterless hand disinfectants may be compared with excess hospital costs associated with nosocomial infections (Table 3). The excess hospital expense associated with four or five nosocomial infections of average severity is equal to the entire annual budget for soap and alcohol products used for hand hygiene in inpatient care areas. A single severe surgical site infection, lower respiratory infection, or bloodstream infection may cost the hospital more than the entire annual budget for antiseptic agents used for hand hygiene. If a change from nonmedicated soap to an antiseptic agent or a substantial increase in the use of antiseptic agents resulted in preventing a few additional nosocomial infections per year, the additional costs associated with using antiseptics would be offset by cost savings.