In this pilot project of TDABC we assessed the costs of time, materials and products required to undertake essential clinical IPC practices by observing 48 healthcare workers in two Quebec hospitals. Our findings reveal that the costs of preventing the transmission of infection are remarkably low, even when the action is performed by the highest paid personnel (median cost being 27.2 cents per action). Weighed against the risk of infection and illness and subsequent monetary and human cost, this analysis supports the existing literature that describes the cost and cost-benefit of investing in resources that support compliance with IPC measures (14, 31–33). This study also importantly provides an assessment of costs of infection prevention in a pre-pandemic context and thus serves as a baseline against which to compare future healthcare economic analyses.
When performed properly, hand hygiene is considered the single most important way to limit the spread of communicable diseases (34). Subjectively, healthcare personnel may consider the time spent on hand hygiene as adequate, however the times recorded in this study did not reach WHO standards (34). Indeed, in our observations, median time for hand washing ranged from 12.41 and 16.04 seconds across personnel, with a median cost of 19.6 cents per action. When using soap and water, the WHO suggests 40–60 seconds for an entire wash from the beginning to the end of the activity; we recorded median times of 22.16 seconds or 55% of the lower WHO limit. When using hydroalcoholic solutions that were wall or table mounted, median times were 13.95 and 13.83 seconds respectively, which also did not meet the WHO standard of 20–30 seconds minimum for rubbing using an alcohol-based formulation, although it came slightly closer at 69% of the lower limit. Compliant hand washing was observed among personnel that used pocket size gel, with a median time of 27.77 seconds which surpassed the minimum limit of 20 seconds by 7 seconds or 39%. This may be due to the ease and efficiency of using a portable hand gel that allows for disinfecting one’s hands during other tasks, such as talking with a patient, or traveling between rooms. Some evidence exists for installing dispensers close to their place of use to improve handwashing compliance (35). However, a recent systematic review outlines challenges with changing hand hygiene habits, and proposes that behaviour change is most successful if it is gradual and supported by leadership in a work environment that emphasizes the importance of patient safety (36, 37).
Environmental contamination is an established risk factor for developing a HCAI, with patient rooms serving as a reservoir for multi drug resistant organisms that may infect new and susceptible patients (38, 39). We observed the cleaning of surfaces as carried out exclusively by hygiene and sanitation staff. The median time for disinfection was 541.53 seconds, or 9 minutes 2 seconds, with a total cost that included products used, of $21.85, or 21.9 cents per action. A longer median time of 14 minutes 32 seconds was observed for terminal cleaning, which is done after patients are discharged or transferred. Enhanced patient room disinfection strategies, including those that target terminal cleaning (40) are essential as viruses such as the corona or influenza virus survive on dry surfaces for a few days, while bacteria such as Methicillin-resistant Staphylococcus aureus (MRSA) can persist for months (41). Despite this, few studies assess the costs of environmental cleaning interventions. One initiative, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study, tested an environmental cleaning bundle in 11 Australian hospitals (33). Five components (product, cleaning technique, training of staff, audit and communication) were implemented with environmental services staff. Outcomes measured included: 1) the reductions of infections per month with the organisms MRSA and Vancomycin-resistant enterococci (VRE); 2) the thoroughness of hospital cleaning and; 3) an economic analysis of costs and savings. The bundle was successful in reducing infections and pathogen counts, and the implementation cost $349, 000 Australian dollars (AUD) but it generated $147, 500 in cost savings. Infections prevented from MRSA and VRE returned a conservatively estimated net monetary profit of $1.02 million AUD. Costs were obtained for the change of type of disinfectant use, as well as for all human resources required to implement and receive training in the intervention, but neither regular human resource (time) nor product/material use were assessed. Considering the importance of hospital environmental cleaning, more micro costing analyses of human and product resource costs are required.
Although this pilot study took place prior to the beginning of the pandemic, the basic and additional precautions undertaken by staff were the CBPs with the highest calculated costs. The donning and removing of personal protective equipment (PPE) had a median total cost of $546.76, or 75.9 cents per action. Twenty percent (20%) of this (16 cents) was attributable to the time it took staff to put on gloves, gowns or masks, while the majority of the cost (80% or 60 cents) represented the materials used per action. For isolation measures, the median total costs were $235.33 for two hours of observation, or $4.13 per action. Over the course of a regular shift of eight hours this would represent a total median cost of $941.32. However, during the study period, no observations of airborne or airborne-contact precautions occurred.
In the current state of the COVID-19 pandemic, PPE is increasingly used for the treatment of all patients, and new equipment such as eye protection (face shield or goggles) is becoming standard practice. This increased use parallels increased costs, as was seen during the Middle East Respiratory Syndrome (MERS-CoV) epidemic. In one hospital in Saudi Arabia with 17 positive cases of MERS, the use of surgical masks increased 5-fold and the use of N 95 masks increased 10-fold per 1,000 patient days (42). In the three month period studied, allowing also for the increase in compliance of hand hygiene, this resulted in a $16,400 per month increase in IPC costs. During this past year, this same driving force in the supply chain, coupled with demand in the general public for PPE, has caused the market demand to explode, resulting in global shortages and price increases (43). In March of 2020, the WHO reported that prices of surgical masks had already increased six fold, N95 respirators had tripled, and surgical gown prices had doubled (44). Our study contributes new knowledge related to pre-COVID-19 costs which will allow researchers to compare future PPE use and cost increases.
Due to the small number (n = 3) of screening tests done during the one-month study period we were unable to calculate the costs of human or product resources for infectious disease screening. Future work planned by our team will allow for a one-year time frame from which to collect data from medical records. This will provide accurate infectious disease screening tests performed without the need for observation.
Overall, the time motion observations using our guide were feasible and acceptable to both the observers and staff being observed. We ensured that the same observer followed a staff member during the course of the study for two hours and 10 minutes each day. The initial 10 minutes was not measured, but allowed the observer to adjust to the tasks and pace being set by the staff member being observed. These procedures allowed for some dissipation of the Hawthorne effect, a known confounder in observational studies of healthcare practices such as hand washing (45). The micro-costing data collected in this study were captured with an observational prospective study design, the optimal technique for obtaining accurate cost estimates to inform resource allocation decisions (24).
Our study has several limitations. We were unable to capture two category costs: those of screening and the costs of materials used for the cleaning of small equipment (missing data). We did not include doctors in this pilot project; their higher wages would augment the average human resource cost across the average costs presented here. To address these limitations and to test the reproducibility of these results, we are undertaking a larger scale study in a context that has been influenced by COVID-19, using the same time motion guide.