The Cost of Compliance

The Cost of Compliance
Ramifications of Hand Hygiene Implementation

By Kathy Dix

The revised hand hygiene guidelines released last fall by the Centers for Disease Control and Prevention (CDC) have been the source of much debate. What have the implications been in healthcare facilities? Have they had trouble complying, or do they disagree with the guidelines?

"We knew that the century-old challenge remained -- getting healthcare workers (HCWs) to wash their hands before and after every patient-care interaction. Yet many of us did not anticipate the challenge of implementing these national guidelines that some suggest are inconsistent with existing laws and regulations," write Gina Pugliese, RN, MS; Judene Bartley, MS, MPH, CIC; and Tammy Lundstrom, MD.1

Reasons for the challenges are both subjective and objective. Some challengers maintain that the CDC's recommendations counter those of the Occupational Safety and Health Administration (OSHA) and other enforcement agencies. Others complain of increased dermatitis with the increased use of alcohol hand rubs -- an effect that runs counter to evidence offered by the CDC.


The CDC guidelines recommend the use of alcohol-based hand rubs as a replacement for much -- but not all -- of soap-and-water handwashing. (Soap and water should still be utilized when visible soiling is present.)

The guidelines also include:

  • A requirement for gloves for bodily fluid contact
  • A requirement that alcohol hand rubs be stored in flammable materials cabinets
  • A recommendation for readily-available hand lotions/creams to prevent dermatitis
  • A recommendation against artificial nails or nail extenders in intensive care units (ICUs) and operating rooms (ORs)
  • A recommendation for compliance monitoring
  • A recommendation that alcohol hand rubs be readily available

Several topics were left unresolved, including:

  • "Routine use" of non-alcohol hand rubs for hand hygiene
  • The wearing of rings in healthcare
  • The volume of hand rub product to use

Obstacles to Implementation

The hand hygiene guideline is confusing, says Nancy Bjerke, RN, MPH, CIC, a Texas-based independent infection control consultant. "And AORN's 2003 Recommended Practice (RP) does not have a new scrub RP to include comment on this new guideline, which pretty much permits operating room managers to proceed as they and/or staff and MDs want," she adds.

Additionally, monitoring of compliance is not being done universally. "Active surgical site infection (SSI) surveillance is not being done, especially in outpatient centers," Bjerke concedes. "Generally, the OR manager makes a mere list of (a physician's) patients that month and the MD signs off if any SSIs have occurred."

Not only that, but the requirements of OSHA, Medicare and the National Fire Protection Association (NFPA) were not addressed specifically in the CDC's guidelines, and this is causing issues with implementation in some facilities. That, Bjerke says, is due to the federal requirements and the responsible persons enforcing the requirements for compliance. "Safety issues -- falls, fire, skin reactions, etc. -- are occurring; not all are being published, however."

The primary -- and most discussion-generating -- recommendation in the new guidelines was the recommendation of alcohol-based hand rubs to replace much of the soap-and-water handwashing previously recommended for healthcare workers.

The sanction of alcohol-based hand rubs has been cause for concern by many -- some worries are valid, while others are simply misconceptions. Rumor has it that OSHA's Bloodborne Pathogen Standard disallows anything but soap and water; however, this is not the case. OSHA and the CDC mandate:

  • Accessible handwashing facilities
  • Alternatives to handwashing when it is not feasible or convenient
  • Handwashing after glove removal or other personal protective equipment
  • Handwashing after contact with blood or other potentially infectious material

Another concern regarding alcohol-based hand rubs is that they may present a significant fire hazard. But the NFPA does not have a specific code or standard regarding this topic. Instead, the NFPA refers to the authority having jurisdiction, who should take into account "the location, amount, use (storage vs. usage) and the medical benefits of such a product."2 Because the NFPA has declined to rule on alcohol hand rubs, various state and local authorities having jurisdiction have offered differing verdicts. For accurate information, refer to the state or local office of fire safety.

Some states have concluded that the benefits of alcohol hand rubs overshadow the possibility of fire and simply recommend that dispensers be located intelligently rather than in high-risk areas.

A third concern is that of corridor obstruction by alcohol gel dispensers. State healthcare facility planning departments are the authorities having jurisdiction; therefore it is appropriate to clear all decisions about dispenser placement through them.

Cost Considerations

Costs for alcohol hand rubs are generally low, and therefore don't much affect overall cost of the hand hygiene program for most facilities. "The cost is being absorbed by the facilities," Bjerke affirms. "(But) not many of the infection control practitioners (ICPs) I asked would quote a price and its return on investment factors."

A teleclass presented last October by Didier Pittet, MD, MS, one of the authors of the CDC guidelines, stresses the low cost of hand hygiene overall compared to the cost of nosocomial infections. According to evidence from a hand hygiene promotional campaign conducted between 1999 and 2001, the "point spread" was astonishing -- nosocomial infections cost an estimated $28.9 million, while the hand hygiene promotional campaign cost one hundred times less -- $288,730.

Pittet notes that time constraints were the main reason for poor compliance with hand hygiene, and that alcohol-based hand rubs were the obvious solution to the problem. And, he stresses, the cost per patient was miniscule. "The cost of $1.62 per admission is probably less than a Big Mac," he adds. "I think a hospital administrator can certainly offer a patient hand hygiene that is less than the cost of a Big Mac."


Acceptance of the guidelines by ICPs has not been a problem for specific classes of healthcare workers. "'The guideline is from the CDC, so it is right and everyone is changing (to comply with it)' is the frequent response (I get) when I personally ask an ICP or an operating room RN," says Bjerke.

Some healthcare facilities have had an easier time accepting the new guidelines than others. In some locations, the first vendor through the door was able to capture the entire business with a subjective acceptance by the HCWs, total house implementation, and no concern about price, says Bjerke. Other locations implemented the alcohol hand rubs after two product evaluations; these facilities made a decision to implement one gel product throughout the entire facility, including ORs; cost was not a factor in this case either.

In a third group of hospitals, a single alcohol-based hand rub was selected for the non-operating room areas; however, the OR continues to use the water-aided choice for antiseptics, which include an alcohol-based product.

A fourth group of facilities implemented alcohol gels universally; they do not require a first scrub with soap and water or nail cleaning for surgical cases. However, this solution may not be the best -- "I have worked some SSI outbreaks, where this has been the major change and the patients have had very negative, costly outcomes, to include litigation," Bjerke cautions.

Monitoring of the outcome of the implementation is not being done universally; some ICPs are monitoring outcomes and SSI incidence, while other ICPs are not monitoring for effect, Bjerke says.

It is not likely that all healthcare sites will agree on the best means of implementation, say Pugliese, et al. And, they continue, existing laws and regulations (or the manner in which they are interpreted and applied) may not coincide with the CDC's recommendations, current science or current recommendations for standards of care. "We should continue to expect inconsistencies in laws vs. science, especially with the rapid pace of evidence-based practice as compared to the glacial pace of changes in laws and regulations," they maintain. "What we can hope for is those individuals that assist with interpretation and enforcement of regulations will recognize these inconsistencies and use a rational and common-sense approach that focuses on quality of care and safety of patients and workers."

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