2.6. HH Observation

The hand hygiene compliance rate among health workers of the two involved institutions was recorded through direct observations by nurses trained on the WHO direct observation method, 24 h a day. The direct observation technique was described in the WHO Hand Hygiene Technical Reference Manual (HHTRM) [15]. According to the HHTRM methodology, only healthcare workers in direct contact with patients are the target of observation. Observations data were collected anonymously. When the observation covers all the healthcare workers in a medical department usually a randomization method was preferred. The methodology adopted proposes sequencing the observation in sessions of limited duration, with each session being conducted in a different setting, with different healthcare workers and at different times. This will generally ensure a representative sample [15]. On average 25 observations per day were performed by trained observers. The nurses who performed the observations were tasked by the nursing coordinator and were involved in the normal clinical activities of the ward. All observations on HH compliance were covert. Data were registered and stored in a dedicated database according the institutional protocols. The data were then retrospectively analyzed.

The overall compliance was calculated by dividing the number of observed HH actions performed when an opportunity occurs, by the total number of opportunities. Generally, a HH compliance of  50% or higher was considered a sufficient compliance [16].

Monitoring HH compliance has been a long-established practice in our institutions. The data was collected and a report was published each month for employees of the department. In our retrospective study we analyzed these previously collected data on HH compliance and correlated with the rate of infections reported in the pre-pandemic and pandemic periods. The method used for the surveys is the same in the 2 periods, according to the institutional protocols.