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Improving Hand Hygiene Compliance in a Resource-Limited ICU Using a Low-Cost Multimodal Quality Improvement Intervention

Sadia Qazi,M. A. Khan,Athar Ud Din,Naimat Saleem,Eshal Atif,Muhammad Atif Mazhar

Published 2026 in Healthcare

ABSTRACT

Highlights What are the main findings? A low-cost multimodal intervention was associated with increased composite hand hygiene compliance in a resource-limited ICU, from 63.1% to 82.0% over a four-week observation period. Sensitivity analysis excluding non-applicable moments demonstrated that pure adherence improved from 54.2% to 82.5%, confirming a genuine behavioral change rather than a measurement artifact. The largest gains occurred in awareness-dependent WHO moments targeted by the intervention (before touching the patient: +27.0 pp; after touching the patient’s surroundings: +40.0 pp), with smaller changes in non-targeted moments. Baseline pure adherence for high-risk moments involving body fluid exposure was substantially lower (12.2%) than that suggested by the primary compliance metric (80.0%), revealing how “compliant by default” scoring can mask poor performance in frequently non-applicable moments. What are the implications of the main findings? Pragmatic, workflow-embedded interventions utilizing education, visual cues, feedback, and leadership engagement can achieve measurable short-term compliance improvements without electronic monitoring or additional resources in resource-limited ICU settings. Episode-based audits with fixed denominators provide operationally feasible tools for directional process monitoring but should be complemented with sensitivity analyses reporting pure adherence to distinguish true behavioral changes from measurement artifacts. Long-term sustainability beyond the four-week observation period remains unknown; extended follow-up at 6–12 months is required to assess the persistence of improvements and the need for ongoing reinforcement. Abstract Background/Objective: Hand hygiene is a cornerstone of infection prevention; however, compliance is inconsistent in intensive care units (ICUs), particularly in resource-constrained settings. This study evaluated whether a low-cost, multimodal quality improvement intervention could improve process-level hand hygiene compliance using routine, episode-based audits embedded in the ICU practice. Methods: We conducted a single-cycle Plan-Do-Study-Act quality improvement project in a 12-bed mixed medical–surgical ICU in Pakistan (December 2023–January 2024). Hand hygiene performance was assessed using the unit’s routine weekly episode-based audit protocol, aligned with the WHO Five Moments framework. A targeted multimodal intervention comprising education, point-of-care visual reminders, audit feedback, and leadership engagement was implemented between the pre- and post-intervention phases (four weeks each). Non-applicable moments were scored as “compliant by default” according to the institutional protocol. A sensitivity analysis was performed excluding these moments to calculate pure adherence. Compliance proportions were summarized using exact 95% Clopper–Pearson confidence intervals without inferential testing. Results: A total of 942 audit episodes (471 per phase) generated 4710 moment-level assessments were generated. Composite hand hygiene compliance increased from 63.1% pre-intervention to 82.0% post-intervention [absolute increase: 18.9 percentage points (pp)]. Sensitivity analysis excluding non-applicable moments demonstrated pure adherence improvement from 54.2% to 82.5% (+28.3 pp), confirming a genuine behavioral change rather than a measurement artifact. Compliance improved across all five WHO moments, with the largest gains in awareness-dependent moments targeted by the intervention: before touching the patient (+27.0 pp) and after touching patient surroundings (+40.0 pp). Week-by-week compliance remained stable within both phases, without immediate post-intervention decay. Conclusions: A pragmatic, low-cost multimodal intervention embedded in routine ICU workflows was associated with substantial short-term improvements in hand hygiene compliance over a four-week observation period, particularly for awareness-dependent behaviors. Episode-based audit systems can support directional process monitoring in resource-limited critical care settings without the need for electronic surveillance. However, its long-term sustainability beyond one month and generalizability to other settings remain unknown. Sensitivity analyses are essential when using “compliant by default” scoring to distinguish adherence patterns from measurement artifacts.

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