the impact of hai includes prolonged hospital stay , long - term disability , increased resistance of microorganisms to antimicrobials , massive additional financial burden , high costs for patients and their families , and excess deaths [ 1 - 3 ] . in october 2005 the world health organization ( who ) started the " clean care is safer care " program to promote safe hand hygiene practices globally and at all levels of health care as a first step in ensuring high standards of infection control and patient safety . the program provided technical recommendations and strategies to improve hand hygiene and included the development of who guidelines on hand hygiene in health care along with a package of practical tools to facilitate implementation activities at a facility level . who recommends hand rub with alcohol - based antiseptic agents as the gold standard procedure to protect patients from the multitude of harmful resistant and non - resistant organisms transmitted by health care workers ' hands , and this easy and fast ( 20 - 30 seconds ) procedure has been associated with reduction in nosocomial infections . differently , standard hand washing with water and soap , is indicated only in case of visibly dirty hands or infection due to spore - forming pathogens [ 6 , 7 ] . the infection control team can use it to evaluate the effectiveness of specific interventions , as well as to introduce changes that minimize the risk of hai . several methods have been suggested to monitor hand hygiene compliance ( direct observation , product use measurement , surveys , electronic systems ) , but the ideal one has not yet been identified [ 8 , 9 ] . who considers direct observation the most effective method to monitor the health care workers adherence to the hand hygiene recommendations , meanwhile the alcoholbased antiseptic agents consumption is a proxy indicator of hand hygiene . in 2006 , italy officially adopted the who program as a mainstay of its strategy for the promotion of hand hygiene in health care settings . " istituto giannina gaslini " ( igg ) children hospital , genoa - italy , a tertiary care pediatric hospital in northern italy , complied with this program since 2007 . the aim of this study was to present a new method to estimate and report on adherence to correct hand hygiene procedures ( chhp)introduced in our hospital since 2007 . istituto giannina gaslini ( igg ) , genoa - italy is a tertiary care children 's hospital in northern italy serving as local pediatric hospital for the genoa area , but representing a tertiary care referring hospital for the whole italy and many foreign countries . in november 2007 , igg joined the " clean care is safer care " who program . this was firstly applied in the pediatric intensive care unit ( picu ) , and then gradually extended to all hospital wards . from january to march 2008 , health care workers started a hand care hygiene educational program , conducted by the nurses of the igg infection control team . " how to " and " 5 moments " posters about hand washing were displayed close to the sinks . beyond the standard antiseptic hand washing , hand decontamination with isopropyl alcohol gel was also recommended . its use was implemented placing alcoholic gel dispenser at the ward entrance and next to each patient location . as the program began , random audits were performed to check the proper application of the procedures ; re - training sessions and meetings with the infection control team nurses were performed when needed . adherence to hand hygiene was initially estimated by means of the amount of antiseptic product supplied , expressed in terms of litres of isopropyl alcohol gel supplied to the unit per 1000 hospitalization - days . however , since this approach could be hard to understand for non - infection control experts , in 2010 another hand hygiene reporting method was introduced , and associated to the first one . as the amount needed for an effective hand hygiene procedure is known for each product ( manufacturer 's instructions ) , we estimated the number of the performed procedures by dividing the total volume of isopropyl alcohol gel ( hereinafter referred also as hand hygiene product ) supplied in a period ( a quarter ) by the volume of the product indicated for an effective hand hygiene procedure . this number was then divided by 90 ( days in a quarter ) and then by the mean number of beds active in each day in the unit in that period ( average bed occupancy in a quarter ) . this calculation should estimate the number of daily chhp procedures performed at each patient 's bed . data about alcoholic gel consumption were collected by each unit head nurse , crossed with data from the pharmacy service supply to any given unit in a given period ( a quarter ) , and communicated to the infection control team . since 2010 the program was gradually extended and in april 2014 , after 4 years of progressive extension to different wards , the method was considered adequate to involve all igg wards . from that moment the infection control team drafted quarterly reports including both the amount of hand hygiene products used by each unit and the estimated number of chhp procedures performed . moreover , the presence of epidemic clusters , defined as an aggregation of cases of infection , without regard to whether the number of cases was more than expected , was evaluated and reported in real time , and it was followed by specific retraining sessions . data were collected on an electronic spread sheet and graphically reported . in order to compare the 2 methods to report on chhp we calculated the pearson correlation coefficient that is a measure of the linear dependence between the 2 methods ( litres/1000 hospitalization days and chhp estimates ) . graphics and correlation coefficient were obtained by means of microsoft office excel 2007 ( microsoft corporation redmond wa ) . figure 1 presents the quarterly reports from april 2014 to march 2016 ( eight trimesters ) of nine selected unites : intensive care units [ pediatric intensive care unit ( picu ) , neonatal intensive care unit ( nicu ) ] , pulmonology , infectious diseases , hemato - oncology , hematopoietic stem cell transplantation , general surgery , neurosurgery , cardiology and cardiovascular surgery . table i reports data on adherence to the hand hygiene program estimated according to two different methods , together with the pearson correlation coefficients between the 2 methods , and show the presence of a positive correlations between the 2 systems that described in the same way changes in procedures for hand hygiene , while figure 1 is the graphic representation of these results . for example , during the third trimester of 2015 in picu , a cluster of acinetobacter baumannii colonization/ infection was followed by an intervention of the infection control team and we observed an increase in hand hygiene procedures compared to the previous trimester , which is reported by both methods ( 47 chhp vs. 19 and 135 litres of hand hygiene products vs 54 , respectively ) ( fig . 1a ) . during the third trimester of 2015 pulmonology ward experienced a cluster of carbapenem resistant enterobacter colonization , and after an intervention of the infection control team we observed an increase of both parameters compared to the previous trimester ( 24 chhp vs 11 and 72 litres of hand hygiene products vs 36 , respectively ) . however , during the fourth trimester of 2015 , when the infection control team intervention became less pressing ( and maybe less persuasive ) , a reduction in the number of hand hygiene procedures ( from 24 to 12 ) was observed : this trend was considered worrisome and induced the infection control team to retrain health workers . the result obtained in the following period ( 14 procedures per patient per day in the first trimester of 2016 ) was still considered not adequate , even if improving , so that a new educational intervention was programmed ( fig . changes in litres of hand hygiene products/1000 hospitalization days ( l/1000 hd ) and estimated hand hygiene ( ehh ) products in different quarters in different wards . quarterly supply hand - hygiene products ( litres/1000 hospitalization days , dark - gray bars ) and estimates of hand - hygiene procedures ( light - gray bars ) and in different wards over 2 years of observation . in general , in icus ( fig . 1a , fig . 1b ) the number of chhp was generally larger compared to medical wards , like pulmonology or infectious disease ( fig . 1d ) . on the other hand , in surgical wards ( general surgery , neurosurgery , cardiovascular surgery ) ( fig . 1i ) the number of estimated procedures was quite similar , constant and relatively low , even if within the standard indicated by the who ( 20 liters/1000 hospitalization days ) , and in absence of any epidemic clusters or high levels of surgical site infections rate . in these wards , the decision was made to periodically retrain the health staff , though with quite frustrating results . unfortunately , all the methods currently used to monitor both standard hand washing and chhp show some limits . for example , direct observation of staff members is currently considered the gold standard in hand hygiene compliance monitoring , but it is time - consuming and requires an adequate number of monitors to be performed frequently in a large number of hospital wards in a reasonably time . on the other hand , direct observation can influence and modify behaviour of health workers when realizing that they are being observed ( so called hawthorne effect ) , leading to falsely elevated compliance rates . starting from a conventional approach , based on measuring litres of isopropyl alcohol gel consumed per 1000 hospitalization - days , the igg introduced a new method , still based on the amount of hand hygiene product , that estimates the mean number of daily chhp performed per patient . our estimate of chhp can be performed using data that can be easily obtained by the hospital administration ( litres of hand hygiene products , days of hospitalization , mean number of patients present in a trimester in a given ward ) . furthermore , the method we adopted to estimate chhp is unobtrusive and allows collecting and reporting real - life information without compartmental bias , even if it does not evaluate if the procedure of hand hygiene is performed in a correct way or not . as shown by this paper , these two methods provide overlapping results in terms of the description of hand hygiene performance over time . in fact there was a very strict positive correlation between these measure methods , with a coefficient > 0.80 in all cases ( in 8/9 cases > 0.94 ) , a value that can be considered very high in social science , where there may be a greater contribution from complicating factors . the new one provides the health staff with a ( estimated ) measure of its hand hygiene performance ( estimated mean number of chhp per patient per day ) , while the other one refers to the amount of hand hygiene products consumed in a unit during a certain period ( litres of product per 1000 hospitalization - days ) . indeed , it is easier to understand one 's own hygiene conduct by thinking in terms of number of hand hygiene procedures than in terms of gel consumption . figure 1 is a realistic picture of the mean daily number of chhp performed per patient per day in each unit . noteworthy these numbers can fluctuate , sometimes widely , from one trimester to another within the same ward . therefore , the main helpfulness of this analysis is to compare each unit against itself over time . however , some observations arise from the comparison among the hand hygiene trend of different units . for example , the higher number of procedures found in intensive care units compared to medical wards is probably due to their different case mix . indeed , intensive care units usually host critical patients , who require constant assistance and frequent invasive procedures and , therefore , a higher number of chhp procedures is expected . on the other hand , the low number of procedures observed in surgical wards , even in absence of epidemic clusters or high levels of surgical site infections , can be at least partially explained by the fact that surgical patients undergoing more complex interventions are usually admitted to intensive care units during the first postoperative phases , which are the most critical periods , while they are referred to surgical wards when a lower level of assistance , and therefore of hand hygiene procedures , is needed . if we consider that the risk of carbapenem resistant enterobacteriaceae transmission can be significantly reduced by performing at least 50% of the required hand washings , it is at least partially understandable that surgical wards could need a relatively low number of procedures to prevent pathogens ' transmission , provided that the volumes of products are adequate , at least according to who standards . these considerations well applies to our pediatric reality and its type of patients and surgical procedures , but they can not be simply transposed to adult or pediatric wards / hospitals with a different case mix . for this reason , we believe that our method of estimating chhp can be used in each setting to compare its own performance in process of time , but can be roughly used to compare different realities in different hospitals or even in the same one . first , it estimates the adherence to chhp but does not provide the real number of performed procedures . second , since it does not include direct observation , it does not allow fixing errors in real time , but only a " post - hoc " retraining . third , it may underestimate adherence to hand hygiene because it does not consider standard handwashing , which is an effective procedure actually used by many health - care workers ( since it is perceived as more secure ) , even if not the currently recommended standard . in conclusion , our experience provides a new , reliable method for measuring hand hygiene adherence that noninfection control experts may find easier to understand , compared to conventional ones . this is a key issue , since no satisfactory infection control can be obtained without the health - care workers collaboration and adherence to hygiene interventions .