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    Original Investigation
    Infectious Diseases
    August 14, 2019

    Inclusion of Real-Time Hand Hygiene Observation and Feedback in a Multimodal Hand Hygiene Improvement Strategy in Low-Resource Settings

    Author Affiliations
    • 1Médecins Sans Frontières, Amsterdam, the Netherlands
    • 2Radboud University Medical Centre, Nijmegen, the Netherlands
    • 3Médecins Sans Frontières, Abuja, Nigeria
    • 4Médecins Sans Frontières, London, United Kingdom
    • 5Anka General Hospital, Anka, Nigeria
    • 6Noma Children’s Hospital, Sokoto, Nigeria
    • 7Médecins Sans Frontières, Brussels, Belgium
    • 8Médecins Sans Frontières, Geneva, Switzerland
    • 9Médecins Sans Frontières, Barcelona, Spain
    • 10Médecins Sans Frontières, Paris, France
    JAMA Netw Open. 2019;2(8):e199118. doi:10.1001/jamanetworkopen.2019.9118
    Key Points español 中文 (chinese)

    Question  Is the implementation of an open-source monitoring and data visualization tool for hand hygiene adherence among health care workers feasible, and does it improve hand hygiene adherence in low-resource settings?

    Findings  In this quality improvement study in 2 hospitals in Nigeria, including 686 preintervention and 673 postintervention observations of moments in which hand hygiene was recommended, overall hand hygiene adherence increased from 32.4% to 57.4%.

    Meaning  Inclusion of real-time monitoring and data visualization in a standard multimodal hand hygiene improvement strategy was associated with successful implementation and increased hand hygiene adherence in these low-resource settings.


    Importance  Hand hygiene adherence monitoring and feedback can reduce health care–acquired infections in hospitals. Few low-cost hand hygiene adherence monitoring tools exist in low-resource settings.

    Objective  To pilot an open-source application for mobile devices and an interactive analytical dashboard for the collection and visualization of health care workers’ hand hygiene adherence data.

    Design, Setting, and Participants  This prospective multicenter quality improvement study evaluated preintervention and postintervention adherence with the 5 Moments for Hand Hygiene, as suggested by the World Health Organization, among health care workers from April 23 to May 25, 2018. A novel data collection form, the Hand Hygiene Observation Tool, was developed in open-source software and used to measure adherence with hand hygiene guidelines among health care workers in the inpatient therapeutic feeding center and pediatric ward of Anka General Hospital, Anka, Nigeria, and the postoperative ward of Noma Children’s Hospital, Sokoto, Nigeria. Qualitative data were analyzed throughout data collection and used for immediate feedback to staff. A more formal analysis of the data was conducted during October 2018.

    Exposures  Multimodal hand hygiene improvement strategy with increased availability and accessibility of alcohol-based hand sanitizer, staff training and education, and evaluation and feedback in near real-time.

    Main Outcomes and Measures  Hand hygiene adherence before and after the intervention in 3 hospital wards, stratified by health care worker role, ward, and moment of hand hygiene.

    Results  A total of 686 preintervention adherence observations and 673 postintervention adherence observations were conducted. After the intervention, overall hand hygiene adherence increased from 32.4% to 57.4%. Adherence increased in both wards in Anka General Hospital (inpatient therapeutic feeding center, 24.3% [54 of 222 moments] to 63.7% [163 of 256 moments]; P < .001; pediatric ward, 50.9% [132 of 259 moments] to 68.8% [135 of 196 moments]; P < .001). Adherence among nurses in Anka General Hospital also increased in both wards (inpatient therapeutic feeding center, 17.7% [28 of 158 moments] to 71.2% [79 of 111 moments]; P < .001; pediatric ward, 45.9% [68 of 148 moments] to 68.4% [78 of 114 moments]; P < .001). In Noma Children’s Hospital, the overall adherence increased from 17.6% (36 of 205 moments) to 39.8% (88 of 221 moments) (P < .001). Adherence among nurses in Noma Children’s Hospital increased from 11.5% (14 of 122 moments) to 61.4% (78 of 126 moments) (P < .001). Adherence among Noma Children’s Hospital physicians decreased from 34.2% (13 of 38 moments) to 8.6% (7 of 81 moments). Lowest overall adherence after the intervention occurred before patient contact (53.1% [85 of 160 moments]), before aseptic procedure (58.3% [21 of 36 moments]), and after touching a patient’s surroundings (47.1% [124 of 263 moments]).

    Conclusions and Relevance  This study suggests that tools for the collection and rapid visualization of hand hygiene adherence data are feasible in low-resource settings. The novel tool used in this study may contribute to comprehensive infection prevention and control strategies and strengthening of hand hygiene behavior among all health care workers in health care facilities in humanitarian and low-resource settings.