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

<b>Background/Objective:</b> 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. <b>Methods:</b> 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. <b>Results:</b> 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. <b>Conclusions:</b> 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.