Addressing hand hygiene compliance in a low-resource neonatal intensive care unit: A quality improvement project

Abstract

Objective: Our goal for this study was to quantify healthcare provider compliance with hand hygiene protocols and develop a conceptual framework for increasing hand hygiene compliance in a low-resource neonatal intensive care unit. Materials and Methods: We developed a 3-phase intervention that involved departmental discussion, audit, and follow-up action. A 4-month unobtrusive audit during night and day shifts was performed. The audit results were presented, and a conceptual framework of barriers to and solutions for increasing hand hygiene compliance was developed collectively. Results: A total of 1308 hand hygiene opportunities were observed. Among 1227 planned patient contacts, hand-washing events (707 [58.6%]), hand rub events (442 [36%]), and missed hand hygiene (78 [6.4%]) events were observed. The missed hand hygiene rate was 20% during resuscitation. Missed hand hygiene opportunities occurred 3.2 times (95% confidence interval, 1.9-5.3 times) more often during resuscitation procedures than during planned contact and 6.14 times (95% confidence interval, 2.36-16.01 times) more often when providers moved between patients. Structural and process determinants of hand hygiene noncompliance were identified through a root-cause analysis in which all members of the neonatal intensive care unit team participated. The mean hand-washing duration was 40 seconds. In 83% of cases, drying hands after washing was neglected. Hand recontamination after hand-washing was seen in 77% of the cases. Washing up to elbow level was observed in 27% of hand-wash events. After departmental review of the study results, hand rubs were placed at each bassinet to address these missed opportunities. Conclusions: Hand hygiene was suboptimal during resuscitation procedures and between patient contacts. We developed a conceptual framework for improving hand hygiene through a root-cause analysis.