The Messy Business of Keeping Clean

Rick Johnson, for HealthLeaders Media, April 15, 2008

Consider how hard it is in the healthcare industry to implement the seemingly simple and sensible. Case in point, the superbugs MRSA and C. difficile have had their way in hospitals around the globe, from the smallest clinics in the developing world to some of the finest state-of-the-art academic medical centers. Despite widespread acknowledgement of the problem--from policymakers, hospital executives, and clinicians--agreement and compliance with basic protocols are often hard to come by.

My colleague, Kathryn Mackenzie noted in this month's HealthLeaders magazine that Britain has recently imposed a dress code for physicians and other clinicians. They no longer can wear sleeves below the elbows, neckties, jewelry, and fake fingernails.

"We are not unique in facing the perils of [hospital-acquired infections]: Every country in the world is grappling with something that has always been a factor in healthcare. We are, however, the only country which has a mandatory universal surveillance system," said Alan Johnson, MP, secretary of state for health for Britain, in a speech last year discussing steps the country has taken to reduce hospital-acquired infection.

Johnson's administration admits that the ban is not supported by hard scientific evidence, but is part of a common sense approach to improve hand hygiene. His policy, however, was not commonly embraced; rather, some charged Johnson with pandering to the media and, in fact, shifting the health system's focus away from proven methods to combat superbugs.

Indeed, some physicians took issue with the health secretary because they felt the new dress code made them appear unprofessional. One doctor quoted in a London newspaper called banning neckties ridiculous: "We wear neckties because patients expect us to look smart, but bow ties will make us look like circus clowns."

Two other physicians, in a letter to the British Medical Journal, said that banning wristwatches could actually harm patients, because a study showed that many doctors are unable to accurately estimate pulse and respiration rates without their wristwatches.

Despite Britain's tribulations with its new dress code, many hospitals are seeing incremental improvements in their quest to shrink patient infection rates. In fact, my colleague, Maureen Larkin pointed out in her Web exclusive column last week that at the organizational level common sense approaches to fighting the spread of dangerous infections can succeed.

But healthcare hygiene efforts need to be carried out with military-like precision and zeal. That means continual reminders and buy-in throughout the ranks of the organization. Like many aspects of clinical care, we are talking about the perils of human decision-making. It takes only a few forgetful employees to deviate from your protocol to greatly increase exposure.

If nothing else, perhaps Britain's well-reported ban will have a psychological effect on caregivers. True, the dress code might not have a direct impact on limiting hospital-acquired infections, but maybe it will remind physicians to pay careful attention to hand hygiene. So the ban might have a kind of transfer effect that delivers real value.

With so much emphasis on the importance of communicating hand-washing protocols, I thought I'd share this short video I spotted on YouTube by Elspeth Connatty, RN, RGN (UK), RM (UK), with the Department of Infection Control for University of San Francisco Medical Center.

If you cannot play the video, here's the URL:

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Rick Johnson is senior online editor of HealthLeaders Media. He may be reached at
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