109

Hospital-acquired infections affect 2 million

patients per year (5%-10% of hospitalized patients)
and are the direct or indirect cause of 88,000
deaths, making them the 8th leading cause of death
in the United States.
1
The incidence of infections in
acute care facilities is approximately 9.8 infections
per 1000 patient care-days,
2,3
resulting in extended
durations of care and contributing to greater costs of
hospitalization and overall costs of care.
1
In addition,
the prevalence of infections caused by antibiotic-
resistant organisms is increasing, and these infec-
tions are associated with significantly higher mor-
tality, prolonged length of stay, and increased costs
to hospitals. The current cost of treating hospital-
acquired infections in the United States is estimated
at $4.5 billion per annum. For these reasons,
attempts to control infections have demanded
increased attention. Since good hand hygiene is
acknowledged as a simple but powerful technique
for preventing hospital-acquired infections, 1 focus
of these infection control measures is compliance
with proper hand hygiene practices.
Handwashing is still considered the most important
and effective infection control measure to prevent
the spread of hospital-acquired infections.
4
However, compliance with handwashing protocols
by health care workers has been, and continues to
be, unacceptably low at 20% to 50%.
2,5-8
Recent
Use of alcohol hand sanitizer as
an infection control strategy in
an acute care facility
Jessica Hilburn, MT (ASCP), CIC
a
Brian S. Hammond
b
Eleanor J. Fendler, PhD
b
Patricia A. Groziak, MS
b
Houston, Texas, and Akron, Ohio
Background: Nosocomial infections are a major problem in health care facilities, resulting in extended durations of care, sub-
stantial morbidity and mortality, and excess costs. Since alcohol gel hand sanitizers combine high immediate antimicrobial effi-
cacy with ease of use, this study was carried out to determine the effect of the use of an alcohol gel hand sanitizer by care-
givers on infection types and rates in an acute care facility. Patients were educated about the study through a poster on the
unit, and teachable patients were given portable bottles of the alcohol hand gel for bedside use, along with an educational
brochure explaining how and why to practice good hand hygiene.
Methods: Infection rate and type data were collected in 1 unit of a 498-bed acute care facility for 16 months (February 2000 to
May 2001). An alcohol gel hand sanitizer was provided and used by caregivers in the orthopedic surgical unit of the facility dur-
ing this period.
Results: The primary infection types (more than 80%) found were urinary tract (UTI) and surgical site (SSI) infections. Infection
types and rates for the unit during the period the alcohol hand sanitizer (intervention) was used were compared with the infec-
tion types and rates for the same unit when the alcohol hand sanitizer was not used (baseline); the results demonstrated a
36.1% decrease in infection rates for the 10-month period that the hand sanitizer was used.
Conclusion: This study indicates that use of an alcohol gel hand sanitizer can decrease infection rates and provide an additional
tool for an effective infection control program in acute care facilities. (Am J Infect Control 2003;31:109-16.)
From the From the Texas Society of Infection Control Practitioners,
Houston,
a
and GOJO Industries, Inc., Akron.
b
Reprint requests: Brian S. Hammond, GOJO Industries, 1 GOJO
Plaza, Akron, OH 44311.
Copyright 2003 by the Association for Professionals in Infection
Control and Epidemiology, Inc.
0196-6553/2003/$30.00 + 0
doi:10.1067/mic.2003.15
110 Vol. 31 No. 2 Hilburn et al
studies
2,9-13
have shown that deterrents to hand-
washing compliance include the amount of time
required for soap-and-water handwashing with
heavy workloads, skin irritation and dryness caused
by frequent handwashing with soap and water, poor
access to sinks, and inadequate knowledge of hand
hygiene guidelines or protocols.
Use of waterless alcohol-based hand sanitizers
instead of soap-and-water handwashing has been
demonstrated to overcome these barriers to compli-
ance.
11-16
These products, generally containing 60%
to 70% ethanol or isopropanol, are one of the most
effective agents for reducing the number of viable
pathogens on the hands,
18-21
including under artifi-
cial fingernails.
22
Hand disinfection with a well-
formulated alcohol gel hand sanitizer containing
emollients has been shown to cause less skin irrita-
tion and dryness of the hands of nurses than has
soap and water.
12
Introduction of easily accessible
dispensers with an alcohol-based waterless hand-
washing antiseptic also has been demonstrated to
lead to significantly greater hand hygiene rates
among health care workers.
8
Improving health care
workers compliance with recommended hand
hygiene measures can reduce transmission of
pathogens
16,17
and result in decreased infection
rates.
17
A recent study
29
in an extended care facility
demonstrated that the use of an alcohol-based hand
sanitizer reduced the infection rates by 30%. The
objective of this study was to assess the effect of the
use of an alcohol hand sanitizer by caregivers on
infection rates and types in an acute care facility.
METHODS
Facility description
This study was performed in a 498-bed acute care
facility with 1700 employees. The facility occupies a
6-story main building with 2-story wings. The first
floor of the main building houses the offices; cafe-
teria; central supply; laboratory; the surgery, dialy-
sis, emergency, radiology, medical records, and
endoscopy departments; and the surgical intensive
care unit. Average daily census is 300, and the infec-
tion control practitioner-to-patient ratio is 1:300.
Study design
This study was performed in the facilitys orthope-
dic surgical unit. The primary fucntion of the unit is
orthopedic surgery, but it also serves as an overflow
for general surgical cases. This unit was chosen as
the trial unit because most of the patients are teach-
able, and staff members were very receptive to the
product and the study. The facility is licensed for
498 beds, but many of the bed spaces have been
converted to office areas and treatment rooms. The
occupancy during the study was consistent with the
real capacity of the facility during that time. In
January 2001, the operating room (OR) was expand-
ed with several rooms, and the new OR was larger
and better-equipped than was the previous OR
space. The staffing on this unit was consistent dur-
ing the study, although the patient-days increased
during the trial.
Baseline infection data were collected for 6 months
on this unit. An alcohol gel hand sanitizer was then
made available for use by the caregivers, patients,
and visitors on the unit for the following 10 months.
In addition, patients were given an educational
brochure on the importance of hand hygiene and
when and how to wash or disinfect their hands with
a hand sanitizer. Teachable patients were given
4.25-ounce containers of the alcohol gel for their
use at bedside.
The promotional campaign consisted of in-services
given to the unit staff upon introduction of the prod-
uct. A poster was placed at the nursing station to
describe the study, use of the product, and indica-
tions for its use. This was available to both the staff
and physicians. Informational brochures were given
to the patients and families. In addition, a poster was
placed on the unit near the elevator for visitors and
families to read; it described the product and the
study. The impact of the increased awareness of
hand sanitation of the patients, families, and visitors
on the increase in hand disinfection by the health
care workers was not measured. Feedback of infec-
tion rates was provided to the staff monthly during
the intervention period. The rates were provided
monthly to the nurse manager of the unit, with a lag
of 2 months. An awareness of this information may
have helped affect the reduction of infections.
Purell Instant Hand Sanitizer (GOJO Industries, Inc,
Akron, Ohio) was used throughout the study. In
vitro antibacterial efficacy and in vivo efficacy of
the sanitizer were determined by Bioscience
Laboratories, Inc, of Bozeman, Mont, with 15-sec-
ond timed exposure kill tests and the Healthcare
Personnel Handwash protocol (a modification of
the American Society for Testing and Materials
No. E 1174-87), respectively. Independent Test
Laboratory of Minneapolis, Minn, similarly evaluat-
ed the product for antiviral efficacy with 30-second
April 2003 111 Hilburn et al
timed exposure kill evaluations for viruses. In addi-
tion, the irritation potential of the product was
measured during the 15 additional product applica-
tion cycles. The results for this data has been pub-
lished previously.
24,25
During the baseline part of the study, handwashing
with Provon Antimicrobial Lotion Soap (Gojo
Industries, Inc, Akron, Ohio) (0.3% chloroxylenol) was
used for hand antisepsis. During the experimental
intervention period, the alcohol gel hand sanitizer was
provided in 1000-mL wall-mounted dispensers locat-
ed immediately inside the doorway of patient rooms.
In addition, 4.25-ounce bottles were available in med-
ication and treatment carts, and the 1000-mL wall-
mounted dispensers were also located at the nurses
stations. Portable 4-ounce bottles were also provided
for use by the nursing staff for carrying in their pock-
et. Patients were given the 4-ounce bottles for their use
at the bedside once they were alert and teachable.
Nursing staff members were instructed to wash their
hands if they were visibly soiled or soiled with organ-
ic material and to use the alcohol hand sanitizer to dis-
infect hands whenever they were not visibly soiled,
specifically between patient care activities, between
procedures, and before administering medications.
Staff members also were encouraged to wash their
hands after every 5 uses of the alcohol hand sanitizer.
Infection data were collected on the unit for 16
months, starting Feb 1, 2000, and ending May 31,
2001. During the first 6 months, baseline infection
data were collected, which served as the control.
During the second 6 months, alcohol hand sanitizer
was used, and infection data were collected to
determine the effect of this hand hygiene interven-
tion. No other changes in infection control practices
were made during this period.
Data collection
For the purposes of this study, an infection was
defined as nosocomial if it developed more than 72
hours after the patient was admitted to the facility.
The staff infection control coordinator carried out
surveillance for nosocomial infections throughout
the facility on the basis of positive culture data.
Surveillance was performed by the infection control
team and was triggered by positive microbiologic
data after 3 days postadmission. If a chart was
pulled, any nosocomial infection recorded in that
chart was recorded, even if no culture was sent for
that infection if clinical data or physician diagnosis
were present. Postdischarge surveillance was not
performed in either leg of the trial. Hospital-wide
surveillance is not conducted at this facility,
although total unit surveillance was done on this
unit during the study trial and intervention periods.
The person responsible for the surveillance is certi-
fied in infection control, with approximately 9
years of experience. Quality control of the data is
performed routinely, including consultation with
the infection control chairman, who is board-certi-
fied in infectious diseases.
Nosocomial infections were diagnosed and classified
according to a combination of the standard defini-
tions of the Centers for Disease Control and
Prevention (CDC).
26
Nosocomial infections were
identified by clinical findings and confirmed by lab-
oratory and/or clinical data or physician diagnosis.
Charts of patients who had any positive culture 72
hours after admission were screened for nosocomial
infections. Charts were reviewed retrospectively both
in the baseline and control periods. If chart review of
any patient revealed any nosocomial infection and
the physicians diagnosed a nosocomial infection, it
was counted as an infection in both baseline and
intervention data. The staff physician determined the
course of treatment. The HNMC laboratory analyzed
specimens, and the results were returned to the
study unit and the appropriate physician. All noso-
comial infections, including the microbiologic data,
were fully documented on standard forms. All of the
infection rate data for the unit were collected and
compiled on standard forms and reported monthly.
The AICE! software program (ICPA, Austin, Tex) was
used for recording and trending this data.
Data analysis
The following 2 measures of the frequency of noso-
comial infections were calculated: (1) the prevalence
of infections, defined as the ratio of the number of
clinically active infections to the total number of
patients studied, and (2) the infection rate, defined
as the ratio of infections per 1000 patient-days
between the control and hand sanitizer periods
(expressed as percentage).
The data were analyzed with standard statistical
techniques. The infection rate was calculated with
the following equation:
(Number of infections
occurring during
Infection rate
the month)
1000 =per 1000 patient-days
(Number of resident-
per 4T per month
days in the month)
112 Vol. 31 No. 2 Hilburn et al
The infection rates per month were analyzed fur-
ther to determine the percent reduction in the infec-
tion rates in the hand sanitizer intervention data
compared with those of the control (baseline) data.
The following equation was used:
Avg. rate of Avg. rate of
infection

infection
(control) (hand sanitizer)
100 = % reduction
Average rate of infection (control)
Average rate of infection (control)
The type of nosocomial infections prevented includ-
ed gastrointestinal infections with Clostridium diffi-
cile, respiratory infections such as bronchitis and
pneumonia, urinary tract infections (UTIs), and bac-
teremias. Surgical site infections (SSIs) were not
reduced at the site and were slightly increased in the
intervention period, but the difference was not sig-
nificant. More than 80% of the infections reduced
were UTIs, as this is the most common type of noso-
comial infection on this unit.
Once the average rate of infection per month was
calculated for each data set, analysis of variance
(ANOVA) was used to calculate the statistical signifi-
cance between the 2 test samples. ANOVA allows the
testing of the differences between the average infec-
tion rate of the control data and the average infec-
tion rate of the product intervention data. ANOVA
does this by examining the ratio of variability
between 2 data sets and the variability within each
data set. Analysis was conducted on a month-by-
month basis and for overall performance for 16
months. Statistical significance for the analysis was
P .05.
Cost analysis
Reducing nosocomial infections is a proven method
to decrease unreimbursed resource utilization and
improve patient care and safety.
33
The prevention of
pain and suffering of patients and improvements in
quality patient care are obvious additional benefits
to the institution and its reputation, which are diffi-
cult to quantify.
An analysis of the cost associated with nosocomial
infections (UTIs) was conducted to determine the
charges associated with UTIs in our institution.
Variables examined included actual charges attrib-
utable to extra length of stay; increased laboratory
charges due to cultures; sensitivities; urinalysis;
monitoring of antibiotics such as vancomycin and
gentamycin; and extra charges of intravenous solu-
tions and equipment, antibiotics, and medications
for 17 patients with nosocomial UTIs. The costs
33
for UTIs are generally considered to be less than
those for other nosocomial infection sites and were
used as a conservative estimate for total infection
costs for the cost analysis. Also, financial data were
readily available for UTIs becaue of their greater fre-
quency of occurrence, and UTIs represented the
infections most frequently prevented.
The patients with UTIs were from the unit studied.
Full financial records of charges associated with
UTIs were determined on the review. Charges such
as laboratory/microbiologic costs, antibiotic costs,
pharmacy costs, IV costs related to the delivery of
antibiotics, and increased length of stay caused by
the UTIs were found on the financial records. The
cost-to-charge ratio of this facility is approximately
65:35. These particular patients developed a UTI in
either the intervention or baseline phase of the unit.
Consultation with patients physicians was sought
to determine whether the UTI caused the increased
length of stay.
The charges billed to the patient were determined
by chart review, and a review of financial charges
and actual costs to the institution were calculated
by multiplying the actual charges to the patient by a
facility-specific cost-to-charge ratio. A cost-to-
charge ratio of 0.7 (provided by Financial Services)
was used, which was believed to represent the aver-
age cost-to-charge ratio.
On the basis of the results of the cost analysis, the
alcohol hand sanitizer was subsequently instituted
housewide in patient units as a cost-effective
method to reduce infections and improve patient
care in the institution.
RESULTS
Infection rates
The primary infection types (more than 80%) found
were UTIs and SSIs. Comparison of the infection
types and rates for the unit when the alcohol hand
sanitizer (intervention) was used were compared
with infection types and rates on the same unit
when the alcohol hand sanitizer was not used (base-
line); a 36.1% decrease in infection rates was
demontrated during the 10-month period when the
hand sanitizer was used. The infection data by
month for the baseline and hand sanitizer period
are provided in Table 1.
April 2003 113 Hilburn et al
The average charges were calculated at $4828.44,
and when adjusted with the cost-to-charge ratio of
0.7 represent an average actual cost to the institu-
tion of $3379.91. The number of nosocomial
infections prevented was calculated as a 36.1%
reduction during the intervention period. The
number of infections prevented was estimated at
27, which was then multiplied by the average actu-
al cost of $3379.91. The average financial savings
during the intervention period were calculated to
be $91,257.57. The range of savings from the min-
imal cost to maximal cost was $13,797.00 to
$316,135.57. The cost analysis data are provided
in Table 2.
DISCUSSION
Hand hygiene is considered to be the most impor-
tant and effective infection control measure to pre-
vent transmission of nosocomial pathogens in
health care settings. The results of hospital-based
studies, published between 1977 and 1995, on the
impact of hand hygiene on the risk of nosocomial
infection have been reviewed by Larson.
17
However,
compliance with handwashing procedures by
health care workers has been, and continues to be,
unacceptably low.
2,5-8,12
Because of the importance
of hand hygiene, several studies have addressed the
issue of noncompliance with hand hygiene guide-
lines.
2,8-10,12,13,16,27-29
The use of waterless alcohol-
based hand sanitizers and rubs instead of soap-
and-water handwashing has been demonstrated to
overcome these barriers to compliance,
11-16
to lead
to significantly higher hand hygiene rates among
health care workers,
8
and to decrease absenteeism
due to illness among elementary school children.
30
The use of alcohol-based hand sanitizers and rubs
has recently been reviewed by Pittet and Boyce
31
and has been found to be the most practical means
of improving hand hygiene compliance.
Several studies have indicated a temporal relation
between improved soap-and-water handwashing
practices and infection rates,
17
and a recent study
16
demonstrated that sustained improvement in hand
hygiene compliance with use of an alcohol hand
rub was associated with decreased infection rates.
However, few clinical studies have focused on what
effect the use of an alcohol gel hand sanitizer for
hand hygiene has on infection rates in acute health
care facilities. One study
32
conducted in a 275-bed
extended care facility demonstrated a significant
reduction in infection rates (29.7%) when an alco-
hol hand sanitizer was made available in dispensers
Table 1. Effects of alcohol gel hand sanitizer use on infection rate by month
Monthly rate of % Reduction in
Total infections per infection rates
Time period patient-days Total infections 1000 patient-days compared to baseline
Baseline period
February 2000 803 6 7.47
March 2000 789 9 11.41
April 2000 743 9 12.11
May 2000 879 8 9.1
June 2000 828 3 3.62
July 2000 826 5 6.05
Average baseline infection rate = 8.2%
Hand sanitizer period
August 2000 865 3 3.47
September 2000 910 3 3.3
October 2000 906 6 6.62
November 2000 894 5 5.59
December 2000 875 6 6.86
January 2001 973 6 6.17
February 2001 854 5 5.85
March 2001 985 5 5.08
April 2001 1008 6 5.95
May 2001 972 4 4.12
Average intervention infection rate = 5.3% 36.1
114 Vol. 31 No. 2 Hilburn et al
at the nursing stations, on medication and treat-
ment carts, and in the dining rooms of the units, in
addition to 4-ounce portable bottles provided to the
nursing staff.
It is possible that patients and visitors can transmit
infections, along with health care workers.
Literature suggests that SSIs and infections acquired
during dialysis can be transmitted to patients via
nasal and hand carriage of Staphylococcus aureus by
the patient. Research is warranted to determine
whether the use of an alcohol hand sanitizer could
reduce patient self-transmission of infections.
Anecdotal comments indicated that the alcohol gel
was very well received by patients and visitors and
was perceived to contribute to greater patient satis-
faction and quality care. No attempt was made to
conduct formal patient-use or visitor-use or satis-
faction surveys, which are areas for further study
and research. No hand hygiene observations were
done of either handwashing or hand sanitizer use
by patients, visitors, or caregivers in either the base-
line or intervention period. This is a limitation to the
study and would be a future adjunct for subsequent
research. Soap usage was not significantly different
during the baseline or intervention period, as mea-
sured by amount of soap ordered by the unit.
Patient-days during the study increased, although
length of stay was not significantly different in the
study. The nurse-to-patient ratio was decreased in
the intervention period (more patients and same
number of nurses). Additional OR rooms were added
to the facility in January 2001, which increased the
number of surgical patients on the unit. There were
slightly more general surgery patients in the inter-
vention period than during the baseline period,
although the difference was minimal.
This 16-month investigation demonstrates the effect
of alcohol hand sanitizer use on reducing infection
rates in an acute care facility and significant cost
Table 2. Nosocomial UTI cost analysis
Cost of Other
Length additional Supply/ Microbiology laboratory Diagnostic IV/PO
Age of stay stay equipment laboratory costs tests medicines IV supplies Total
70 29 $1475 $217 $667 $496 $13 $4229 $1200 $8297
68 26 $1475 $187 $1758 $119 $0 $4642 $6450 $15709
74 11 $575 $64 $513 $351 $138 $1128 $0 $2769
65 10 $1475 $187 $232 $260 $0 $2651 $0 $4805
97 17 $800 $45 $653 $842 $743 $3424 $1425 $7932
75 7 $800 $0 $101 $199 $162 $227 $62 $1551
92 39 $8100 $738 $1388 $768 $402 $3886 $1444 $16726
62 9 $800 $0 $681 $584 $120 $2136 $907 $5228
82 8 $550 $54 $116 $225 $0 $212 $0 $1157
58 6 $995 $0 $116 $64 $0 $94.50 $0 $1269.50
40 3 $550 $0 $116 $64 $0 $0 $0 $730
78 22 $425 $0 $345 $151 $0 $1077.50 $82 $2080.50
76 42 $500 $0 $622 $656 $240 $2122.40 $0 $4130.40
80 22 $450 $0 $306 $443 $0 $779.50 $41 $2019.50
81 30 $800 $380 $755 $469 $0 $2456 $0 $4860
59 9 $800 $0 $377 $133 $0 $312.25 $0 $1622.25
73 5 $800 $0 $101 $357 $120 $93 $0 $1471
Mean $4828.44
Median $2769
Range $15996.75
Minimum $730
Maximum $16726.75
Sum $82083.40
Standard $4868.37
deviation
Count (n) 17
April 2003 115 Hilburn et al
savings associated with infection prevention.
Comparison of the infection rates for the baseline
period with those for the experimental alcohol hand
sanitizer period showed a 36.1% decrease in infection
rates for the 6-month period, with an average esti-
mated infection prevention cost savings of
$91,257.57. The cost of the intervention (product cost)
for the 10-month period was calculated to be $1688.
CONCLUSION
The continued emergence and control difficulties
with multidrug-resistant pathogens, such as
methicillin-resistant S aureus, vancomycin-resistant
enterococci, and extended spectrum -lactamase-
producing gram-negative bacilli, are major prob-
lems in acute care and long-term care facilities
alike. Alcohol hand sanitizers have the greatest
antimicrobial efficacy and speed of kill against
these resistant pathogens and help improve com-
pliance because they are convenient, quick to use,
and gentle on the skin. Consequently, use of these
products as part of an infection control program
can have a significant impact on both health out-
comes and health care costs.
The use of an alcohol hand sanitizer by caregivers
in an acute care facility was demonstrated to signif-
icantly reduce the infection rates and resulted in a
significant cost savings by preventing the spread of
nosocomial infections during a 10-month interven-
tion period. This study indicates that use of an alco-
hol gel hand sanitizer is an effective strategy in a
hospital infection control program.
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