Leapfrog Defends Hand Hygiene Standard After Concerns Raised by APIC

By Jay Kumar

The Leapfrog Group defended its hand hygiene observation requirement but will re-evaluate it after a leading infection prevention association insisted Leapfrog’s standard misinterprets accepted guidance.

In August, the Association for Professionals in Infection Control and Epidemiology (APIC) sent a letter to Leapfrog Group President and CEO Leah Binder, asserting that Leapfrog’s current standard of 200 observations per hospital per month is not supported by the World Health Organization’s (WHO) 2009 hand hygiene guidelines.

In a press release, APIC says the WHO doesn’t recommend a fixed monthly minimum, but instead a cumulative approach of 12-15 observations per denomination, repeated over several weeks; this should lead to a total of 150-200 observations over time to ensure statistical significance. APIC’s release says the clarification was provided directly by the WHO after the association made a formal request.

“Leapfrog’s requirement is based on a misinterpretation of WHO’s intent,” said APIC CEO Devin Jopp in the statement. “This standard has led to excessive observation burdens that divert critical resources away from more impactful infection prevention efforts.”

Reached for comment, Binder responded to APIC’s statement.

“I think that APIC is a really important organization and we’re aligned with them on quite a lot of things. We really respect infection preventionists. They’re saving a lot of lives,” she says. “So we certainly are going to be closely following anything they send us.”

Leapfrog’s standard is in part based on the WHO standard, but not in whole, Binder notes.

“Their standard and what they’ve talked about around hand hygiene opportunities should be monitored,” she says. “They don’t have a number, so we developed one with our expert panel and research from Johns Hopkins. That’s where we got to 200 [hand hygiene opportunities] need to be observed per month per unit.”

Binder explains Leapfrog’s rationale for the standard.

“The reason that ours is higher than the 50 is because we want hospitals to reliably monitor not just where they are right now on compliance, but whether that’s an improvement or a deterioration from where they were last month,” she says. “And statistically speaking, in order to observe a 10% difference from last month to this month, you have to have 200 each month. So that is why we’ve gone to the 200 because we do think it’s very important that they be assessing the change and improvement, hopefully over time.”

Binder says APIC’s concerns are understandable.

“But we take the point that IPs are very concerned about 200. And by the way, our standard does not require 200 human observations if you have electronic hand hygiene equipment and at least 10% of hospitals do have that,” she adds. “But we take the point that it’s something that the IPs want us to look closely at because it is an issue for them and we respect their perspective on this and we’ll take another look. Our expert panel does include infection preventionists. So it’s not that we haven’t considered that perspective at all.”

That said, Binder notes that a higher standard for hand hygiene is sorely needed.

“Well, we’re seeing a higher level of compliance with our overall policy, which is very gratifying,” she says. “Unfortunately, we still don’t have a way of monitoring the actual rates of compliance by hospital. We don’t have a standard yet that where we can measure that.”

Still, hand hygiene compliance is trending upward.

“Unfortunately, we don’t have that [type of standard] yet, but the compliance with our standard—which is a tough standard—has grown considerably and I think that’s really good,” Binder says. “I think it’s now 10% of hospitals that have adopted electronic hand hygiene monitoring, it used to be less than 5% even a couple of years ago. So that’s a rapid increase, which I think is a good trend, too. We’re seeing movement in the right direction and we don’t want to slow that movement down. We want that to accelerate.”

Binder says this isn’t the first time Leapfrog’s standard has raised concerns.

“We’ve heard the concern around that the 200 observations is a lot,” she says. “We’ve heard that from hospitals so it wasn’t surprising to hear that [from APIC]. We appreciated that they had a study that was peer-reviewed. That’s good evidence for us to look at.”

Leapfrog is currently evaluating the study referenced by APIC.

“We’re going to bring their concerns to the expert panel and we’re talking to the World Health Organization because they apparently told APIC that our standard was contradicting theirs,” says Binder. “We don’t see the contradiction, we see that they have not named how many observations they recommend. So we’re not really contradicting that, but maybe we’re missing something. So we are talking to the [WHO] because that’s of course a concern as well.”

The Leapfrog standard is more specific than the WHO’s, she notes.

“Leapfrog sets standards. We don’t just ask for data and [ask] ‘How are you doing?’” Binder says. “We actually set a standard: This is what excellent looks like. Are you there or how close are you? And so that’s why we’re clear on what we believe is the right standard for hand hygiene monitoring.”