The long-sleeved monogrammed lab coat, steeped in medical tradition and infectious bacteria, will become a relic if guidelines on clinician attire from the Society for Healthcare Epidemiology of America are taken seriously by hospitals and health systems.
What should conscientious medical clinicians wear to avoid contaminating their patients with bacteria that can lead to infections?
A better question might be 'what should they NOT wear?'
The thought crosses my mind whenever I'm out and about in the neighborhood because I live in the shadow of two major tertiary hospitals. Always there are doctors, nurses, and technicians in lab coats or scrubs going about their non-clinical business.
I've even seen clinicians in scrubs (and even flip-flops)
- At the bank
- At the grocery store
- Walking their dogs (and carrying poop bags )
Female clinicians seem to wear a lot of necklaces and bracelets. Some men wear neckties. A few of them have dangling hospital IDs on lanyards around their necks. And most wear rings.
I've even seen doctors' neckties flapping over grocery carts. Is this okay? Or is it dangerous?
This week, a paper from the Guidelines Committee of SHEA, the Society for Healthcare Epidemiology of America, addressed many of these issues, outlining what we know about infection transmission through attire, and a lot of what we don't, and offering guidance until we figure it all out.
Old Habits Die Hard
Gonzalo Llorens Bearman, MD |
Bearman is a Professor of Medicine and Associate Hospital Epidemiologist at the Virginia Commonwealth University with a focus on infectious diseases, internal medicine, epidemiology, international medical relief and clinical research.
As the committee's report says, old habits, such as the long-sleeved monogramed lab coat, "is steeped in culture and tradition." And old habits do die hard.
"We know that healthcare worker apparel can get colonized with bacteria, whether it's a lab coat or a tie or even a scrub top," Bearman explains. "But there's no slam dunk evidence to prove that colonized apparel results in cross-transmission to cause a hospital-acquired infection. That's the state of knowledge."
"So what we are doing is making some recommendations based on biologic plausibility—what we think is reasonable and feasible, and not difficult to implement."
Bearman stresses that these recommendations are all voluntary, and applicable to all inpatient settings in acute care hospitals except the operating room, which has its own requirements. Here are a few of the committee's recommendations.
1. Bare below the elbows, or BBE
This means short sleeves, no wristwatches, no jewelry and no ties during clinical practice. One important reason for this policy is to encourage providers to wash their hands to the wrists between patient encounters.
"What we try to do is decrease the bioburden at the point of care in the inpatient setting," Bearman says. "So by not wearing a long sleeve, not having a cuff, not having a wristwatch on or wrist jewelry, it's much easier to do hand hygiene that's effective to at least the level of the wrist or midforearm."
2. White Coats
Each provider should have two or more, and should have a convenient and economical way to launder these coats. Asked if hospitals should be encouraged to launder those coats to avoid home laundering at potentially insufficiently high temperatures, Bearman says "there's no real data to suggest where it should be laundered. In theory, if you have an industrial laundry in the hospital that uses high temperature washes and puts things in a drier at high temperature, that should probably eradicate all bacteria and spores, and in theory that would be superior, and a boon, but there nothing to support that in the literature.
A hospital laundry service would eliminate the possibility that providers would wear scrubs or other attire in their communities, where they could be potentially infected, only to return to the hospital with those same pathogens. Clinicians could simply put on their clinical garb after they arrive at the hospital, and take it off before they leave. That too makes sense, Bearman says, but there's no evidence to date that it prevents hospital-acquired infections.
Clothing that comes into contact with the patient or a patient's environment should be laundered after daily use, the guideline suggests. But white coats should be laundered "no less frequently than once a week and when visibly soiled."
3. Coat Hooks
The SHEA guidelines call for organizations to provide coat hooks where white coats and other long-sleeved outerwear can be placed prior to patient contact.
Andrew Shulman, MD, PhD |
This would mean that during rounds, clinicians would be spending a lot of time taking their coats off and putting them back on again. And what if two or more clinicians need to see the patient at the same time? Who gets to use the hook?
4. Neckties
The committee did not find enough evidence to tell healthcare providers they can't wear neckties, saying their role in transmission "remains undetermined." Bearman explains that studies have shown that neckties can become colonized with pathogens, and there's "biologic plausibility that neckties could dangle on patients, devices, wounds or skin and potentially cross transmit a pathogen," there's no evidence that it has.
Just to be on the safe side, however, especially since ties are rarely if ever washed in hot water (unless by mistake), clinicians should avoid neckties. But if they feel they must wear them, "at the very least fasten it so that it doesn't dip into or come into direct contact with a patient. You could have a coat or vest that holds it back, or a tie clip, or you could simply have a button in your dress shirt and tuck the tie in."
Another idea: Wear a bow tie. Andrew Shulman, MD, PhD, a pediatric rheumatologist on Orange County, CA, is a bow tie wearer and advocate who has written about why he wears them. (He was not involved with the SHEA study.)
5. Footwear
No open-toed shoes. (This means you Dr. Flip Flop.) "All footwear should have closed toes, low heels, and non-skid soles," say the SHEA guidelines.
6. Wearable Equipment and IDs
Shared equipment, including stethoscopes, should be cleaned between patients, the guidelines say.
One might think that the infection preventionist would have concerns about lanyards carrying hospital identification, tags, cell phones, pagers and jewelry, but the committee said "no guidance can be offered regarding prohibiting" such items. It did say that "those items that come into direct contact with the patient or environment should be disinfected, replaced or eliminated.
7. Rings
The committee report doesn't specifically mention whether men and women should stop wearing rings, including wedding bands, because "we didn't find enough data to step out on that particular limb," Bearman says. But he noted that the United Kingdom prohibits providers there from wearing rings during direct patient care.