Article Text

Quality improvement initiative ‘S-A-F-H’ to reduce healthcare-associated neonatal sepsis in a tertiary neonatal care unit
  1. Aditya Kallimath1,
  2. Suprabha K Patnaik1,
  3. Nandini Malshe1,
  4. Pradeep Suryawanshi1,
  5. Pari Singh1,
  6. Reema Gareghat1,
  7. Vinaya Nimbre2,
  8. Kalyani Ranbishe2,
  9. Archana Gautam Kamble2,
  10. Vishwas Ambekar3
  1. 1Department of Neonatology, Bharati Vidyapeeth Deemed University Medical College, Pune, India
  2. 2Nursing Department, Bharati Hospital, Pune, Maharashtra, India
  3. 3Infection Control Department, Bharati Hospital, Pune, Maharashtra, India
  1. Correspondence to Dr Suprabha K Patnaik; drsipi{at}


Background Neonatal sepsis is a leading cause of morbidity and mortality among admitted neonates. Healthcare-associated infection (HAI) is a significant contributor in this cohort.

Local problem In our unit, 16.1% of the admissions developed sepsis during their stay in the unit.

Method We formed a team of all stakeholders to address the issue. The problem was analysed using various tools, and the main contributing factor was low compliance with hand hygiene and handling of intravenous lines.

Interventions The scrub the hub/aseptic non-touch technique/five moments of hand hygiene/hand hygiene (S-A-F-H) protocol was formulated as a quality improvement initiative, and various interventions were done to ensure compliance with hand hygiene, five moments of hand hygiene, aseptic non-touch technique. The data were collected and analysed regularly with the team members, and actions were planned accordingly.

Results Over a few months, the team could reduce the incidence of HAI by 50%, which has been sustained for over a year. The improvement in compliance with the various aspects of S-A-F-H increased.

Conclusions Compliance with hand hygiene steps, five moments of hand hygiene and an aseptic non-touch technique using quality improvement methodology led to a reduction in neonatal sepsis incidence in the unit. Regular reinforcement is required to maintain awareness of asepsis practices and implementation in day-to-day care and to bring about behavioural changes.

  • nosocomial infections
  • sepsis
  • continuous quality improvement
  • healthcare quality improvement

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Quality improvement initiatives are simple and practical steps to improve healthcare practices.

  • Neonatal sepsis reduction is a challenge for the neonatal intensive care units (NICUs).


  • Compliance with simple interventions resulted in a reduction in neonatal sepsis in the NICU.

  • Regular reinforcement is required to maintain awareness of asepsis practices and implementation in day-to-day care, as behavioural changes are necessary.


  • Focusing on scrub the hub/aseptic non-touch technique/five moments of hand hygiene/hand hygiene protocol can lead to a reduction in neonatal sepsis rates in units without additional resource requirements.


Neonatal care has seen rapid advances over the past few decades, leading to improved survival of preterm and other sick neonates. However, neonatal sepsis has been a serious challenge and is one of the leading causes of neonatal mortality worldwide, accounting for nearly 15% of neonatal deaths.1 A hospital-based collaborative network study from India demonstrated that neonatal sepsis accounted for 14.3% of neonatal intensive care unit (NICU) admissions and contributed to 24% of neonatal deaths.2 Healthcare-associated infections (HAIs) or nosocomial infections in NICUs contributing to late-onset neonatal sepsis (LONS) after the first 72 hours of life have been an increasing concern in most NICUs.3 The incidence of HAIs is 50%, with 20-fold higher rates in low- and middle-income countries (LMICs) than in high-income countries.4 The mortality rate can be as high as 80%, depending on the risk factor.5 6 The adverse neurodevelopmental outcomes, prolonged hospital stays and healthcare costs in LONS are well established.7 The major interventions to reduce the problem of HAIs are improvements in reporting and surveillance systems, identification of local factors of infection, application of standard precautions, with a specific focus on aseptic techniques and improving staff education, competency and skill.8–10 Neonates admitted to NICU experience substantial instrumentation during their hospital stay, predisposing them to acquire HAIs. There is suboptimal compliance with evidence-based measures in LMICs, which is one of the root causes of high infection rates in such settings.11 12

We are a 60-bed tertiary-level NICU in Pune, Maharashtra, India that admits 150 neonates per month with referrals from around a 50 km radius of the city. Forty per cent of the admitted babies in the unit are premature and have low birth weight. The majority of the admitted babies are intramural (60%). In April–May 2021, we had an increased incidence of HAIs in our NICU, with reported incidence rates of around 16% of admitted neonates per month. To reduce HAIs in our NICU, we undertook a quality improvement (QI) initiative to reduce the incidence of HAIs by 50% in 3 months and then sustain it.


Healthcare associated infections in NICUs lead to increased mortality, adverse neurodevelopmental outcomes, prolonged hospital stays and increased cost of healthcare.13 Due to suboptimal compliance with evidence-based measures in LMICs, these settings have had high infection rates.14 QI initiatives have been undertaken in LMICs to reduce central line-associated bloodstream infection (CLABSI)/LONS rates with various degrees of success, improving healthcare quality in NICUs.15–18 Devices and procedures are considered the most common risk factors for HAIs.19 Hand hygiene is the single most important intervention in interrupting the transmission of microorganisms, thus preventing HAIs. Although this appears easy to follow, implementation is often more challenging than expected, with low compliance rates even in NICUs.20 The aseptic non-touch technique (ANTT) is based on well-defined principles that aim to standardise the procedures by maintaining an aseptic field and protecting key parts and sites from touch with potentially contaminated hands and items.21

Although there was an established infection control protocol in our unit, we noted a gap in the knowledge and practice, leading to an increase in HAIs in April–May 2021. The incidence rates of HAIs averaged around 16% of admitted neonates in NICU over these 3 months, which led to significant morbidity and mortality. To address the increase in HAI rates, we formed a team of neonatologists, residents of the NICU and nursing staff. We included the infection control nurse, microbiologist, antimicrobial stewardship programme team and housekeeping representatives focusing on reducing the HAI rates.

The team got together for brain-storming sessions and took the opinions of all staff involved in patient care in the NICU. Figure 1 depicts the root cause analysis of the problem the team was attempting to address. The main contributing factors identified were partial compliance with hand hygiene practices and other infection control practices, especially while handling vascular access by the healthcare providers.

Figure 1

Root cause analysis of the increased incidence of healthcare-associated infection (HAI) in the unit. ANTT, aseptic non-touch technique; HH, hand hygiene; NICU, neonatal intensive care unit; VAP, ventilator-associated pneumonia.

Measurement indicators

We took up this QI initiative to decrease the incidence of HAIs in our unit. The process indicators measured were the compliance rates to ANTT with particular emphasis on scrubbing the hub, five moments of hand hygiene and steps of hand hygiene. The other process indicator was the conduct of short sessions regarding scrub the hub/aseptic non-touch technique/five moments of hand hygiene/hand hygiene (S-A-F-H) protocol during hand-offs every shift by the nursing staff. This served as a reflection of reinforcing the critical steps for infection prevention among the nursing staff. The primary outcome indicator measured was the incidence rates of HAIs as a percentage of total admissions in the unit. HAI was defined as an infection not present and without evidence of incubation at the time of hospitalisation and was diagnosed according to the criteria of the Centers for Disease Control and Prevention.22 Other outcome indicators included HAI rates per 1000 patient days and antibiotic usage per 1000 patient days. We retrieved the baseline data of HAIs and neonatal characteristics from monthly audits of the NICU. The information regarding HAIs was collected and documented in real-time in our NICU; weekly data were collected and collated monthly in the first week of the month for the previous month by a neonatology resident. The data source was the doctor’s duty register for the outcome indicators. The paediatric residents posted in the various levels of NICU were responsible for collating the outcome indicators, and the process indicator was extracted from the observation Google form (online supplemental file 1) and nurses’ daily communication register.

Supplemental material


This QI study was conducted in the tertiary-care neonatal unit from May 2021 to June 2023. The unit comprises 18 intensive care beds, 22 level II beds and 20 beds in the level I neonatal unit. The team did a gap analysis for the increased rates of HAIs, including the fishbone analysis, to understand the width of the problem (figure 1). The main issues identified were partial compliance with infection control practices in the unit and a need for more awareness among healthcare workers about the aseptic non-touch technique. Also, adherence to the central line care bundle and ventilator care bundle could have been better. Although there is surveillance done by the infection control nurse regarding the practices in the unit, the system is not robust, is biased in terms of the timing of observation and does not reflect the ongoing practices. The team first focused on establishing a surveillance system where the information regarding current practices in the NICU was noted and discussed. We came up with the acronym S-A-F-H, which translates to cleanliness in the Hindi language. We chose this acronym because of its simplicity and effective way of identifying and implementing our goals. Since a lot of communication and close coordination were required, a discussion group on WhatsApp software for mobile devices was formed for this initiative to keep all stakeholders in the loop. We decided to convene a meeting every Tuesday, discuss the previous week’s actions, decisions and outcomes and create an agenda for the coming weeks. During the sessions, the nature of the responsibilities of various members was taken into consideration, and a priority listing of the duties was done as per their availability. The meetings helped the team understand the multiple roles and responsibilities of each member.

Team briefings were documented, and data collection was performed by the team coordinator and posted in groups every week for data sharing. Parents were not actively involved in the implementation of the project or were not part of regular review meetings. However, parents of neonates admitted were taught hand hygiene practices through pictorial charts or practical demonstrations by nursing staff at the time of handling the baby for any purpose (Kangaroo mother care or oral feeding) and when neonates were with their mothers. Parents were encouraged to observe care being given to the neonate and, if they found any deficiencies in aseptic practices by any team member, to register their concerns with the senior staff, and accordingly, corrections were implemented.

After establishing the surveillance and data tabulation system, the next challenge was increasing knowledge and awareness among healthcare workers and reinforcing aseptic practices to sustain them for prolonged periods and make them a norm in our unit. The prediction was that with improvement in awareness and consistent teaching, adherence to asepsis techniques would increase, leading to a decreased incidence of HAIs.


The study consisted of three predetermined phases, namely, phase I, which consisted of baseline data collection (2 weeks); phase II, the intervention phase (16 weeks) and phase III, a sustenance phase (88 weeks). The team wanted to bring out behavioural changes in the unit towards asepsis practices. The team decided to test the change ideas and carried out many plan-do-study-act (PDSA) cycles.

Plan-do-study-act cycle 1

(Formulation of S-A-F-H protocol)

QI team formulated a protocol to reduce HAI rates. Presentations were prepared, and pamphlets regarding the S-A-F-H protocol were printed. The team discussed and narrowed down these critical steps for targeted focus.

Simple presentations highlighted the various aspects of S-A-F-H, which every staff and resident could understand. Opinions were taken from relevant healthcare workers, and the protocol was prepared according to ease of understanding. The S-A-F-H protocol presentations designed were shown to 20 healthcare workers, along with a demonstration; they were well understood by all of them and were found to be helpful to follow during their day-to-day patient care duties. The team adopted the S-A-F-H protocol.

Plan-do-study-act cycle 2

(Focused observation of infection control practices using S-A-F-H printed forms)

The QI team created an observation checklist in printed form with relevant questions about asepsis practices. It was distributed in printed format to staff nurses and residents to fill in observations over a week. Both staff nurses and residents could only observe and fill out the forms occasionally. Observation numbers were poor (5 out of 50 forms), and it was not easy to tabulate the data—this change in printed forms required some adaptation.

Plan-do-study-act cycle 3

(Focused observation of aseptic practices using S-A-F-H Google forms)

QI team created a Google form with relevant questions about asepsis practices. The team created a checklist in Google forms (online supplemental file l). The form link was uploaded to all computers of the NICU and sent to all team members on mobile phones. During the testing week, the residents and the nurses could complete the form without compromising the clinical care. After creating the Google form, it was feasible and easy for staff and residents to fill in the data. The team captured 230 observations in that week. It was also easy for the team to collect and tabulate the data and present them in pictorial graphs for sharing with the members. The form required a few iterations to capture the various steps of S-A-F-H to identify the missing steps or poorly performed steps to help the team members reinforce the steps during the meetings. The team adopted this change idea to improve observations and collections of data.

Plan-do-study-act cycle 4

(Group reinforcement of S-A-F-H protocol in every shift change—handing-taking over time)

QI team members decided to conduct group reinforcement sessions on S-A-F-H practices in every shift. Staff members briefly discussed aseptic practices during handing-taking over time, using the S-A-F-H forms and presentations. There was concern regarding the availability of time for the sessions during clinical care. Hence, the session was designed to last <5 min and conducted during the shift change nursing huddle. These sessions were carried out for 3 days. During all nine opportunities, the nursing staff could find time during shift changes to discuss aseptic practices and to increase awareness among themselves. Also, they found it helpful in self-clinical care practices and observation form filling. The team adopted the idea of group sessions during the nursing huddle as a means of reinforcement among staff members.

Plan-do-study-act cycle 5

(Conduct weekly focused group discussions)

QI team members decided to meet every Tuesday of the week to discuss the findings of the previous week and plan next week’s agenda. Weekly focused group discussions were planned, and QI team members also involved other staff members to formulate plans. To share data from last week and also to take regular sessions on S-A-F-H with attending members to improve awareness, the team conducted focused group discussions. During these meetings, the attendees discussed the challenges faced by the team members. We tested it over 3 weeks, and the representatives of the stakeholders could come for the meeting. The meetings were scheduled in the afternoon, during the incoming nursing staff shift. This meeting timing was conducive for the staff to attend without clinical care compromise. The in-charge nurses also found it convenient to participate and as an opportunity for data sharing and reinforcement of S-A-F-H protocol. The team adopted the idea of regular focused group discussion.

Plan-do-study-act cycle 6

(Compliance with the standard of protocols for CLABSI

During the meeting, the central line insertion and maintenance care bundles not being followed were highlighted by members. Standard of protocols (SOPs) were already in place for these bundles but were being followed only 50% of the time. They were added in weekly discussions to be implemented with checklists. Weekly, the bundle care was discussed. Real-time checklists and observations were done for these specific procedures for the maintenance of asepsis. The checklist was made available in the NICU and was followed up diligently. Over the next 2 weeks, compliance with the checklist was adhered to 10 out of 11 times. The team could use real-time checklist during procedure and did not find it challenging to use. One time the form was not available, hence the team ensured regular printed supply of forms in the unit. This change in the idea was adopted with a specific focus on residents during insertion and nursing staff during maintenance.

Plan-do-study-act cycle 7

(To create a SOP for the handling of the ultrasound machine)

During the meetings, the team members highlighted the urgent need for a protocol in place for the handling of ultrasound machines as it was observed that the infection control practices were not followed by the neonatal fellows, hence predisposing to cross-infection in the unit. We made a protocol for cleaning and handling ultrasound machines during procedure and postprocedure. The protocol created was taught to all residents using the machine. The staff checked compliance. This protocol and its compliance were followed for 3 days. During this time, out of 20 uses of the machine, the protocol was adhered to 18 times. This protocol faced no challenges and was changed to SOP and was adopted.

Plan-do-study-act cycle 8

(Adherence to barrier nursing protocol)

As the unit has neonatal sepsis cases and limited isolation rooms, it was decided to follow the barrier nursing protocol to prevent cross-infection strictly. A protocol was devised by the infection control nurse and was introduced. The protocol included using separate gowns, wearing gloves, caps and masks, and regular cleaning of the environment of the septic neonate, in addition to the usual aseptic practices. A checklist of the protocol with timings for the activities was placed near every bed of any neonate suspected of or having proven sepsis. The nursing staff could adhere to the protocol with the expectation of preventing the spread of infection in the unit. This was tested over next 7 days. For all three suspected sepsis babies during that time, the staff could adhere to the newly formulated barrier nursing protocol. The protocol was easy to follow and was adopted.

Plan-do-study-act cycle 9

(Regular training of newly posted residents and staff)

QI team noted that every month, new residents and staff keep getting posted in the NICU who are unaware of the S-A-F-H practices. A programme was created where individual classes were taken to newly joined members in the NICU by designated QI team members. Simple theoretical and practical classes were taken for new members. Before and after questionnaires were formulated to evaluate their level of understanding, and this idea was adopted. Every new member was taught within a few days of joining, and the responsibility was assigned to the senior nursing staff and the infection control nurse. During the next rotation of residents, five residents came and all residents joining the unit were trained for the same by the neonatal fellow within a week of their joining and the idea was adopted by the team.

QI team noted that compliance to S-A-F-H was suboptimal as the sustenance phase went on. The QI team used weekly group discussions to reinforce S-A-F-H practice. Weekly data were shared in group discussions and WhatsApp groups to keep awareness at optimal levels. Weekly group discussions and the sharing of data and materials in WhatsApp groups were conducted by the QI team over 88 weeks. Compliance rates were monitored, and at any level of decrease in care, rates of group discussions were increased accordingly. The compliance rates to S-A-F-H were consistently maintained and improved from the baseline phase. This change idea had a positive impact in our unit by reinforcing knowledge, raising awareness and bringing about behavioural change.


During the study period, 3146 admissions took place in the NICU, averaging 131 monthly admissions. Two hundred eleven neonates (6.7%) were diagnosed to have had HAIs during their course of hospital stay. Out of 211 neonates, 165 neonates (78.1%) were diagnosed with culture-positive sepsis, and 46 neonates (21.8%) had clinical sepsis. Process and outcome indicators were observed during the study period.

Process indicators

The process indicators measured were the compliance rates with aseptic practices. Process indicators include adherence to all steps of ANTT, hand hygiene and hand washing. The process was classified as satisfactory/full compliance if all steps were done correctly. Any deviance from the protocol or incompletion of steps was deemed unsatisfactory.

The observations were done by nursing staff, residents and infectious disease department workers while performing various day-to-day procedures in the NICU. Self-observations were also encouraged. Google forms were created with all the relevant questionnaires, shared with all staff members involved in the care of neonates in the NICU, and uploaded to computers at all NICU stations. The process of filling out the forms was explained to all the caretakers of the NICU. Process indicators (ANTT, hand hygiene, hand washing) were categorised as whether they were done correctly, incorrectly or skipped altogether. The designation of the healthcare provider observing the process and filling the forms, along with the designation of the healthcare provider who was observed during the process, was also required to be filled. The data were collected weekly and shared with the team members in the weekly meetings by the senior residents. Every month, an average of the process indicators was tabulated from the weekly data and expressed in percentage by the senior resident in charge of data collection. The observed compliance to ANTT, hand hygiene and hand washing in the baseline phase in May 2021 was 62%, 79% and 84%, respectively. After the intervention phase and formation of the S-A-F-H protocol and implementation of PDSA cycles, the compliance rates improved to above 90% for all the process indicators and remained sustained above 90% throughout the study period (figure 2).

Figure 2

Process and outcome indicators of the quality improvement initiative for healthcare-associated infection (HAI) reduction in the unit. ANTT, aseptic non-touch technique; S-A-F-H, scrub the hub/aseptic non-touch technique/five moments of hand hygiene/hand hygiene.

Outcome indicators

The mean HAIs incidence rates showed a reduction from 16.1% in phase I to 8.4% in phase II. This further reduced to 6% in the sustenance phase with a reduction of 62.8% compared with phase I in the incidence of HAIs rates (figure 2).

There was a decrease in mean HAI rates per 1000 patient days from 21.8 in phase I to 10.9 in phase II. During phase III, the mean HAI rate was 8.1 per 1000 patient days, a reduction of 62.9% compared with phase I (figure 2).

The antibiotic usage per 1000 patient days was 419 in phase I followed by a mean of 404 and 345 in phases II and III, respectively. Despite a decrease in HAIs rates by 50%, our antibiotic usage decreased only by 17.7% (figure 2).


We set out with this QI project with a simple message of S-A-F-H, which was meant to keep a clean unit. S-A-F-H was a message which could be conveyed to all healthcare workers in the most simplistic terms. We could achieve our goal of reduction of HAIs in admitted neonates in our unit by 50%. This project focused on using QI principles in order to address the problems and shortcomings and create a plan forward using simple evidence practices like hand hygiene, ANTT and hand washing techniques, and healthcare personnel training with regular and sustained reinforcement.

The compliance rates of asepsis practices increased from 70% to >90% after the initial training period. With regular training and repeated reinforcements, we observed that compliance with asepsis practice was improving over time and had become a routine practice in our unit. We could observe behavioural changes and more sensitivity towards asepsis practices. We had a reduction of 60% in both incidence rates of HAIs and HAIs rates per 1000 patient days. Although we had a 50% decrease in the incidence of HAIs, we could decrease the antibiotic usage in our unit only by 17.7%.

QI projects have been successfully conducted in other units for the reduction of CLABSI rates.16 18 QI studies done on ANTT for the reduction in HAIs also have shown positive results.17 These QI projects were also done in low- and middle-income settings with the objective to reduce their sepsis rates. Regular observations of everyday routine procedures along with bundle approaches and assessment of knowledge on a regular basis were key to our success in the implementation of our QI project. Similar studies have shown that a sound surveillance system, checklist-guided practices and care bundle approaches have decreased CLABSI rates.18 20 23

We wanted a more holistic approach towards decreasing sepsis in our unit, and not just individualise for CLABSI or ventilator-associated pneumonia, hence the initiative of S-A-F-H. The first PDSA cycle was formulating the team and protocols and laying out the plan in clear and simple terms. In PDSA cycles 2 and 3, we wanted to have focused observations of the current asepsis practices in the unit. Google observation forms turned out to be a boon for us in this aspect, showing that using simple technology can help improve practices in the unit. PDSA cycle 4 focused on group reinforcements during handover time, and PDSA cycle 5 emphasised weekly focused group discussions. In the sixth PDSA cycle, CLABSI prevention bundles were formulated and followed. The seventh PDSA cycle was primarily focused on our handling of the ultrasound machine as a source of the spread of infection. A protocol was created to use the machine where asepsis can be followed. Barrier nursing was addressed in PDSA cycle 8. In PDSA cycle 9, the emphasis was on new staff joining to NICU. As a teaching medical hospital, we have a rotation of nurses and residents who keep changing once every 2–3 months. Every time a change happens, compliance with asepsis practice used to decrease. So, the focus was to have individualised training for every new member joining our NICU team within few days.

Neonatal sepsis was one of the main causes of morbidity and mortality. Hence, this project aimed to create an emphasis on adhering to asepsis practices to decrease the burden of sepsis on the neonate and the parent alike. As the study period went ahead, the importance of asepsis practices was understood by all healthcare workers involved, and change could be found in daily practices. This project was implemented into a part of the training protocol of every healthcare worker involved in NICU care. During this period, mortality attributable to HAI varied from 0% to 1% of all admissions, and all-cause mortality ranged from 0% to 2.9% of all admissions. There was no noticeable consistent change in reduction in mortality due to HAI in the unit. The average yearly mortality rates in the unit has been consistently below 2% in the last 5 years.

We had the desired results after the intervention phase with the decrease in the incidence of HAIs rates, but sustaining it further was the main objective of the QI project. We noticed that compliance with S-A-F-H was suboptimal as the sustenance phase went on. This was the most challenging task we had at hand, maintaining the enthusiasm towards decreasing the HAIs by improving compliance towards asepsis practices. This was achieved by having weekly group discussions, regular reinforcement, focused observations and keeping the morale of the unit on the positive side.

We attributed the success of reduction of sepsis in our unit to this project, as the average number of admissions per month, intermural and extramural admissions, were similar prior to the start of the project and throughout the project period. Neonatal characteristics were also similar prior to and after the implementation of the project. S-A-F-H was the only QI project in our unit targeting lower sepsis rates during this whole period. The core team members for the project were the same during the whole project. The rotation of residents and nursing staff in the unit was similar prior to and after the implementation of the project. Hence, confounding factors seemed unlikely in this project, and the reduction of sepsis has been attributed to all the healthcare workers unit who were involved in this project.

Lessons and limitations

This study was conducted in an LMIC setting, nurturing both inborn and outborn neonates. We used simplified messaging to attain our goal. With regular reinforcements, we could sustain compliance with asepsis practices and reduce our incidence of HAIs over 88 weeks. The observations were done by all the stakeholders and entered into the Google form. We could analyse the steps requiring reinforcements and hence had focused interventions. We could use the hand-off times to reach the maximum stakeholders, and the weekly meetings were instrumental in improving compliance.

This study also had a few limitations. Interobserver variability was present in the observation of compliance with asepsis practices. We tried to take care of this by having regular sessions on what to observe while observing the S-A-F-H protocol and how to fill out the observation forms. Also, compliance with infection control practices is challenging as there is a behavioural element that requires frequent reinforcement until it transforms into a habit. Parents’ involvement in the project meetings was minimal, but their practices in the NICU were a focal point of the intervention.


Although neonatal sepsis remains an increasing concern in NICU, leading to morbidity and mortality, it was possible to improve infection control practices among healthcare workers with a systematic and stepwise approach to QI. Compliance with simple interventions resulted in neonatal sepsis reduction and its sustenance in the unit. Regular reinforcement, monitoring, team engagement and adherence to the protocol are required to bring about behavioural changes leading to better clinical care and outcome, as was seen in our study. Compliance with S-A-F-H protocol reduced NICU infection rates in our unit, and similar results can be achieved in other settings too. The reduction in sepsis rates will result in healthier individuals and reduce psychological and financial burden on the family.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Ethics approval

An institutional ethical committee review was not sought as the quality improvement initiatives being studied were evidence-based and widely accepted internationally.


We thank all the residents, nursing staff and multipurpose healthcare workers in the neonatology department for participating in this initiative. We thank the infectious disease department of Bharati Hospital for their active participation. We also thank the Nationwide Quality of Care Network (NQOCN), India, for encouraging this work.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Correction notice This article has been corrected since it was first published.Figure 1 has been updated.

  • Contributors All listed authors certify that they have participated sufficiently in the project. PS and SKP provided the project conception and supervision. Design and acquisition of data were undertaken by AK, NM, RG, PsH, VN, KR, AGK and VA. Analysis and interpretation of data were done by AK and SKP. The initial draft of the manuscript was undertaken by AK, while its editing was completed by SKP, NM and PS. All authors provided their inputs in the manuscript and approved the final manuscript. SKP is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.