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 theCenters for Disease Control and Prevention (CDC) have been the source of muchdebate. What have the implications been in healthcare facilities? Have they hadtrouble complying, or do they disagree with the guidelines?

"We knew that the century-old challenge remained -- gettinghealthcare workers (HCWs) to wash their hands before and after everypatient-care interaction. Yet many of us did not anticipate the challenge ofimplementing these national guidelines that some suggest are inconsistent withexisting laws and regulations," write Gina Pugliese, RN, MS; JudeneBartley, MS, MPH, CIC; and Tammy Lundstrom, MD.1

Reasons for the challenges are both subjective and objective. Somechallengers maintain that the CDC's recommendations counter those of theOccupational Safety and Health Administration (OSHA) and other enforcementagencies. Others complain of increased dermatitis with the increased use ofalcohol 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 areplacement for much -- but not all -- of soap-and-water handwashing. (Soap andwater 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, aTexas-based independent infection control consultant. "And AORN's 2003Recommended Practice (RP) does not have a new scrub RP to include comment onthis new guideline, which pretty much permits operating room managers to proceedas 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 ORmanager makes a mere list of (a physician's) patients that month and the MDsigns off if any SSIs have occurred."

Not only that, but the requirements of OSHA, Medicare and the National FireProtection Association (NFPA) were not addressed specifically in the CDC'sguidelines, and this is causing issues with implementation in some facilities.That, Bjerke says, is due to the federal requirements and the responsiblepersons 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 newguidelines was the recommendation of alcohol-based hand rubs to replace much ofthe 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 itthat 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 asignificant fire hazard. But the NFPA does not have a specific code or standardregarding this topic. Instead, the NFPA refers to the authority havingjurisdiction, who should take into account "the location, amount, use(storage vs. usage) and the medical benefits of such a product."2Because the NFPA has declined to rule on alcohol hand rubs, various state andlocal authorities having jurisdiction have offered differing verdicts. Foraccurate information, refer to the state or local office of fire safety.

Some states have concluded that the benefits of alcohol hand rubs overshadowthe possibility of fire and simply recommend that dispensers be locatedintelligently 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 havingjurisdiction; therefore it is appropriate to clear all decisions about dispenserplacement through them.

Cost Considerations

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

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

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


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

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

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

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

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

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